Provider Demographics
NPI:1942567466
Name:PENDLETON, JASON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:PENDLETON
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 1:1637 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2853
Mailing Address - Country:US
Mailing Address - Phone:608-781-3999
Mailing Address - Fax:
Practice Address - Street 1:1637 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650
Practice Address - Country:US
Practice Address - Phone:608-781-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-22
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7118151223G0001X
IA30353390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program