Provider Demographics
NPI:1780021832
Name:PECK, JASON MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:PECK
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 1:6222 FM 1374 RD
Mailing Address - Street 2:
Mailing Address - City:NEW WAVERLY
Mailing Address - State:TX
Mailing Address - Zip Code:77358-3930
Mailing Address - Country:US
Mailing Address - Phone:936-203-0166
Mailing Address - Fax:
Practice Address - Street 1:4518 CENTER ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-6351
Practice Address - Country:US
Practice Address - Phone:281-479-2841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX289951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice