Provider Demographics
NPI:1134403009
Name:LACOURSE, JASON C (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:C
Last Name:LACOURSE
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 1:2441 21ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5582
Mailing Address - Country:US
Mailing Address - Phone:270-412-6027
Mailing Address - Fax:
Practice Address - Street 1:2441 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5582
Practice Address - Country:US
Practice Address - Phone:270-412-6027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7735000-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice