Provider Demographics
NPI:1205042785
Name:SOUYIAS, JASON G (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:G
Last Name:SOUYIAS
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 1:1175 THOMAS EDISON DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8500
Mailing Address - Country:US
Mailing Address - Phone:810-987-1400
Mailing Address - Fax:810-987-1349
Practice Address - Street 1:1175 THOMAS EDISON DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8500
Practice Address - Country:US
Practice Address - Phone:810-987-1400
Practice Address - Fax:810-987-1349
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010192001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics