Provider Demographics
NPI:1053321067
Name:HOMAN, JARED SCOT (DDS)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:SCOT
Last Name:HOMAN
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 1:733 W. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1757
Mailing Address - Country:US
Mailing Address - Phone:920-324-4218
Mailing Address - Fax:920-345-1228
Practice Address - Street 1:733 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1757
Practice Address - Country:US
Practice Address - Phone:920-324-4218
Practice Address - Fax:920-345-1228
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60301223G0001X
WI6030-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice