Provider Demographics
NPI:1578622908
Name:LEE, JASON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:LEE
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 1:3263 GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13820 OLD ST AUGUSTINE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-260-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP4771223S0112X
AZD75211223S0112X
FLDN185541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA461503733AMedicaid
FL0767638-00Medicaid
FLAG125ZMedicare PIN