Provider Demographics
NPI:1659393023
Name:BOOTH, JASON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:BOOTH
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 1:15294 W BROOKSIDE LN
Mailing Address - Street 2:STE 100
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-3999
Mailing Address - Country:US
Mailing Address - Phone:623-376-7400
Mailing Address - Fax:623-376-7489
Practice Address - Street 1:15294 W BROOKSIDE LN
Practice Address - Street 2:STE 100
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3999
Practice Address - Country:US
Practice Address - Phone:623-376-7400
Practice Address - Fax:623-376-7489
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ55421223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics