Provider Demographics
NPI:1265642151
Name:SEYMOUR, JASON G (DMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:G
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 E HICKORY AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2735
Mailing Address - Country:US
Mailing Address - Phone:850-682-4724
Mailing Address - Fax:
Practice Address - Street 1:297 E HICKORY AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2735
Practice Address - Country:US
Practice Address - Phone:850-682-4724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00140291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice