Provider Demographics
NPI:1508882465
Name:HAVARD, JASON SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:SCOTT
Last Name:HAVARD
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:PO BOX 11020
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-0018
Mailing Address - Country:US
Mailing Address - Phone:501-730-0375
Mailing Address - Fax:
Practice Address - Street 1:2700 ALLYSON LANE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-730-0375
Practice Address - Fax:501-730-0335
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152983608Medicaid
AR5X909OtherBLUE CROSS BLUE SHIELD