Provider Demographics
NPI:1013403237
Name:BRISBIN, JASON JAMES (RDH, PHRDH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:JAMES
Last Name:BRISBIN
Suffix:
Gender:M
Credentials:RDH, PHRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13256 EMILINE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68138-6108
Mailing Address - Country:US
Mailing Address - Phone:402-813-1312
Mailing Address - Fax:
Practice Address - Street 1:13256 EMILINE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68138-6108
Practice Address - Country:US
Practice Address - Phone:402-813-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2827124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist