Provider Demographics
NPI:1760535298
Name:VETTRAINO, JASON T (DDS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:T
Last Name:VETTRAINO
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 1:43380 WOODWARD AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5050
Mailing Address - Country:US
Mailing Address - Phone:248-338-3550
Mailing Address - Fax:
Practice Address - Street 1:43380 WOODWARD AVE STE 107
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5050
Practice Address - Country:US
Practice Address - Phone:248-338-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI19218122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124832641Medicaid