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Individual
MR. JARED WAYNE MACK
Active
Individual
MR. JARED WAYNE MACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
57690
CA
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
11959048
UT
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
57690
CA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
08/18/2008
Last updated
01/16/2023
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