Provider Demographics
NPI:1497778997
Name:WHITT, JASON RANDALL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RANDALL
Last Name:WHITT
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 1:21743 SW ASPEN PL
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-6061
Mailing Address - Country:US
Mailing Address - Phone:503-692-4497
Mailing Address - Fax:
Practice Address - Street 1:1314 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1127
Practice Address - Country:US
Practice Address - Phone:503-280-2877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice