Provider Demographics
NPI:1770838138
Name:COUCH, JASON BARTLETT (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BARTLETT
Last Name:COUCH
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 1:6668 LONETREE BLVD
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3752
Mailing Address - Country:US
Mailing Address - Phone:916-782-4604
Mailing Address - Fax:916-782-7932
Practice Address - Street 1:6668 LONETREE BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3752
Practice Address - Country:US
Practice Address - Phone:916-782-4604
Practice Address - Fax:916-782-7932
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA614931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice