Provider Demographics
NPI:1184144651
Name:OUTLAW, JASON LANIER (DMD, DMSC)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:LANIER
Last Name:OUTLAW
Suffix:
Gender:M
Credentials:DMD, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DORCHESTER AVE
Mailing Address - Street 2:#51237
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02205
Mailing Address - Country:US
Mailing Address - Phone:312-731-5818
Mailing Address - Fax:
Practice Address - Street 1:1575 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02126-2122
Practice Address - Country:US
Practice Address - Phone:617-296-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1858198122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program