Provider Demographics
NPI:1043558984
Name:ALLRED, JASON M
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:ALLRED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 PUTTER LN
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-8900
Mailing Address - Country:US
Mailing Address - Phone:218-371-1820
Mailing Address - Fax:
Practice Address - Street 1:206 1ST ST SE
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1561
Practice Address - Country:US
Practice Address - Phone:218-631-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT20125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist