Provider Demographics
NPI:1346310034
Name:DITTBERNER, JASON (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DITTBERNER
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 1:750 N KENDRICK ST STE 200
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1599
Mailing Address - Country:US
Mailing Address - Phone:928-773-7900
Mailing Address - Fax:
Practice Address - Street 1:750 N KENDRICK ST STE 200
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1599
Practice Address - Country:US
Practice Address - Phone:928-773-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice