Provider Demographics
NPI:1053577130
Name:CARDON, JEREMY G (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:G
Last Name:CARDON
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 1:718 MALETA LN
Mailing Address - Street 2:STE 102
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-7602
Mailing Address - Country:US
Mailing Address - Phone:303-814-9899
Mailing Address - Fax:
Practice Address - Street 1:718 MALETA LN
Practice Address - Street 2:STE 102
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-7602
Practice Address - Country:US
Practice Address - Phone:303-814-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600343021223G0001X
NMDD3475122300000X
CODEN.00202126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE60034302OtherWASHINGTON STATE DENTAL LICENSE