Provider Demographics
NPI:1699935403
Name:WALDEN, JARRETT HARRELL (DMD)
Entity type:Individual
Prefix:DR
First Name:JARRETT
Middle Name:HARRELL
Last Name:WALDEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 GENTILLY RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5148
Mailing Address - Country:US
Mailing Address - Phone:912-764-6861
Mailing Address - Fax:
Practice Address - Street 1:108 GENTILLY RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5148
Practice Address - Country:US
Practice Address - Phone:912-764-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist