Provider Demographics
NPI:1588408504
Name:JD ONLINE LLC
Entity type:Organization
Organization Name:JD ONLINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-389-9333
Mailing Address - Street 1:1327 N STANFORD LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019
Mailing Address - Country:US
Mailing Address - Phone:509-389-9333
Mailing Address - Fax:509-891-4741
Practice Address - Street 1:23403 E MISSION AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019
Practice Address - Country:US
Practice Address - Phone:509-645-2640
Practice Address - Fax:509-891-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No302F00000XManaged Care OrganizationsExclusive Provider Organization