Provider Demographics
NPI:1114166378
Name:CHAISON, JEREMY B (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:B
Last Name:CHAISON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19214 BOTHELL WAY NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-6066
Mailing Address - Country:US
Mailing Address - Phone:425-483-2828
Mailing Address - Fax:425-485-8781
Practice Address - Street 1:19214 BOTHELL WAY NE
Practice Address - Street 2:SUITE A
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-6066
Practice Address - Country:US
Practice Address - Phone:425-483-2828
Practice Address - Fax:425-485-8781
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000111611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics