Provider Demographics
NPI:1366512832
Name:JARDENIL, DAVID SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SCOTT
Last Name:JARDENIL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 LANCER ST
Mailing Address - Street 2:STE. B
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4490
Mailing Address - Country:US
Mailing Address - Phone:219-762-1806
Mailing Address - Fax:219-763-9979
Practice Address - Street 1:3204 LANCER ST
Practice Address - Street 2:STE. B
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4490
Practice Address - Country:US
Practice Address - Phone:219-762-1806
Practice Address - Fax:219-763-9979
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120089111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200178640Medicaid
IN901629OtherUNITED CONCORDIA