Provider Demographics
NPI:1477576106
Name:IZZI, JASON ROGER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ROGER
Last Name:IZZI
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 1:1351 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-3340
Mailing Address - Country:US
Mailing Address - Phone:401-353-2045
Mailing Address - Fax:401-354-8488
Practice Address - Street 1:1351 SMITH ST
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02911-3340
Practice Address - Country:US
Practice Address - Phone:401-353-2045
Practice Address - Fax:401-354-8488
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI25811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI8761-8OtherBLUE CROSS
RIJI27223Medicaid