Provider Demographics
NPI:1144759028
Name:STREETER, JASON BLAINE (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BLAINE
Last Name:STREETER
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 1:4159 PARK HAVEN VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-2604
Mailing Address - Country:US
Mailing Address - Phone:208-431-4187
Mailing Address - Fax:
Practice Address - Street 1:1685 BRIARGATE BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3464
Practice Address - Country:US
Practice Address - Phone:719-590-7277
Practice Address - Fax:719-590-7278
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002031801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice