Provider Demographics
NPI:1891027181
Name:OUELLETTE, JASON PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:PATRICK
Last Name:OUELLETTE
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 1:1254 GARRISON DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1075
Mailing Address - Country:US
Mailing Address - Phone:404-414-0106
Mailing Address - Fax:
Practice Address - Street 1:455 MAGNOLIA AVE STE B
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4838
Practice Address - Country:US
Practice Address - Phone:180-076-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19187122300000X
GADN014030122300000X
FLDN 191871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist