Provider Demographics
NPI:1467438523
Name:JAMISON, SIMUEL LAZAAR (DMD)
Entity Type:Individual
Prefix:
First Name:SIMUEL
Middle Name:LAZAAR
Last Name:JAMISON
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:DEPT OF THE ARMY, DENTAL ACTIVITY, STOP B
Mailing Address - Street 2:2817 REILLY RD, MCDS-NA-B
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-396-5610
Mailing Address - Fax:910-396-7017
Practice Address - Street 1:DEPT OF THE ARMY, DENTAL ACTIVITY, STOP B
Practice Address - Street 2:2817 REILLY RD, MCDS-NA-B
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-396-5610
Practice Address - Fax:910-396-7017
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74351223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
BJ7032244OtherFEDERAL DEA