Provider Demographics
NPI:1619342417
Name:BREWER, JASON KOTERO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:KOTERO
Last Name:BREWER
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 1:81 SUNNYBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-9322
Mailing Address - Country:US
Mailing Address - Phone:601-899-2414
Mailing Address - Fax:
Practice Address - Street 1:2700 N HILLS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2641
Practice Address - Country:US
Practice Address - Phone:601-485-4851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3833-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice