Provider Demographics
NPI:1538329818
Name:KNELLER, JASON MATTHEW
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MATTHEW
Last Name:KNELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1181 OLD COUNTRY RD
Mailing Address - Street 2:SUTIE 4
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5018
Mailing Address - Country:US
Mailing Address - Phone:516-822-7880
Mailing Address - Fax:
Practice Address - Street 1:1181 OLD COUNTRY RD
Practice Address - Street 2:SUTIE 4
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-5018
Practice Address - Country:US
Practice Address - Phone:516-822-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0562641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery