Provider Demographics
NPI:1437132537
Name:BLACKHAM, JASON T (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:T
Last Name:BLACKHAM
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 1:101 BODIN CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-7083
Mailing Address - Fax:707-423-7117
Practice Address - Street 1:60 MDG/SGIC
Practice Address - Street 2:101 BODIN CIR
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1800
Practice Address - Country:US
Practice Address - Phone:707-423-7083
Practice Address - Fax:707-423-7117
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT264631-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice