Provider Demographics
NPI:1871542480
Name:CONDIE, JARED CRAIG (DMD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:CRAIG
Last Name:CONDIE
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 1:589 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5056
Mailing Address - Country:US
Mailing Address - Phone:801-429-2000
Mailing Address - Fax:801-429-2001
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:U S A F ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89981223G0001X
UT6654264-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice