Provider Demographics
NPI:1780856849
Name:HARTUP, JASON KYLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:KYLE
Last Name:HARTUP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 HARMON LOOP RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-6519
Mailing Address - Country:US
Mailing Address - Phone:671-482-2936
Mailing Address - Fax:
Practice Address - Street 1:505 HARMON LOOP RD
Practice Address - Street 2:SUITE 300
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6519
Practice Address - Country:US
Practice Address - Phone:671-482-2936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-29
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56525122300000X
GUD1009122300000X
UT665127889031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice