Provider Demographics
NPI:1730481359
Name:OLITSKY, JASON SAMUEL
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:SAMUEL
Last Name:OLITSKY
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 1:818 A1A N
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3295
Mailing Address - Country:US
Mailing Address - Phone:904-273-1723
Mailing Address - Fax:904-273-1726
Practice Address - Street 1:818 A1A N
Practice Address - Street 2:SUITE 209
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3295
Practice Address - Country:US
Practice Address - Phone:904-273-1723
Practice Address - Fax:904-273-1726
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN157911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice