Provider Demographics
NPI:1336394568
Name:BACON, JASON TROY (DDS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:TROY
Last Name:BACON
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 1:3701 W. NORTHWEST HWY
Mailing Address - Street 2:STE #306
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220
Mailing Address - Country:US
Mailing Address - Phone:214-353-0683
Mailing Address - Fax:972-764-8760
Practice Address - Street 1:3701 W. NORTHWEST HWY
Practice Address - Street 2:STE #306
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220
Practice Address - Country:US
Practice Address - Phone:214-353-0683
Practice Address - Fax:972-764-8760
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA578781223G0001X
TX243811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice