Provider Demographics
NPI:1275634032
Name:BLACK, JASON ALEXANDER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALEXANDER
Last Name:BLACK
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 1:3624 N HILLS DR STE A103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3061
Mailing Address - Country:US
Mailing Address - Phone:512-346-3631
Mailing Address - Fax:512-346-1381
Practice Address - Street 1:3624 N HILLS DR STE A103
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3061
Practice Address - Country:US
Practice Address - Phone:512-346-3631
Practice Address - Fax:512-346-1381
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice