Provider Demographics
NPI:1316208630
Name:JASON R. ESTEP, DMD, PLLC
Entity Type:Organization
Organization Name:JASON R. ESTEP, DMD, PLLC
Other - Org Name:POPLARVILLE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:ESTEP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-795-8024
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-0073
Mailing Address - Country:US
Mailing Address - Phone:601-795-8024
Mailing Address - Fax:601-795-0745
Practice Address - Street 1:1718 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-4287
Practice Address - Country:US
Practice Address - Phone:601-795-8024
Practice Address - Fax:601-795-0745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3549-101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06858257Medicaid