Provider Demographics
NPI:1770212409
Name:PRUETT, JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:PRUETT
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 1:2794 HIGH CEDARS LN
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-3416
Mailing Address - Country:US
Mailing Address - Phone:801-245-0502
Mailing Address - Fax:
Practice Address - Street 1:11 ROSSANLEY DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-1713
Practice Address - Country:US
Practice Address - Phone:541-797-6152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12886440-9923122300000X
CODEN.002052161223G0001X
ORD121691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist