Provider Demographics
NPI:1184075293
Name:LAN, JASON BO
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BO
Last Name:LAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11825 GREENBRIER LN
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-8342
Mailing Address - Country:US
Mailing Address - Phone:661-513-6787
Mailing Address - Fax:
Practice Address - Street 1:8750 19TH ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701-4608
Practice Address - Country:US
Practice Address - Phone:909-483-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist