Provider Demographics
NPI:1316043847
Name:JASPER, SAMUEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:JASPER
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 1:800 ROSE ST RM D104
Mailing Address - Street 2:UNIVERSITY OF KENTUCKY COLLEGE OF DENTISTRY
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0297
Mailing Address - Country:US
Mailing Address - Phone:859-323-6193
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST RM D104
Practice Address - Street 2:UNIVERSITY OF KENTUCKY COLLEGE OF DENTISTRY
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0297
Practice Address - Country:US
Practice Address - Phone:859-323-6193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5169122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60051695Medicaid
KY60051695Medicaid
KY0037840Medicare ID - Type UnspecifiedINDIVIDUAL