Provider Demographics
NPI:1134613565
Name:JASON E SHOCKLEY MS, DDS, PLLC
Entity type:Organization
Organization Name:JASON E SHOCKLEY MS, DDS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DDS
Authorized Official - Phone:970-824-9785
Mailing Address - Street 1:580 PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-3047
Mailing Address - Country:US
Mailing Address - Phone:970-761-3365
Mailing Address - Fax:970-824-2215
Practice Address - Street 1:580 PERSHING ST
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-3047
Practice Address - Country:US
Practice Address - Phone:970-824-9785
Practice Address - Fax:970-824-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00203594261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental