Provider Demographics
NPI:1467449207
Name:POTTER, JASON K (MD, DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:K
Last Name:POTTER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93982
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0119
Mailing Address - Country:US
Mailing Address - Phone:214-930-6588
Mailing Address - Fax:
Practice Address - Street 1:8220 WALNUT HILL LN
Practice Address - Street 2:SUITE 206
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4427
Practice Address - Country:US
Practice Address - Phone:214-930-6588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25735204E00000X
TXM6345174400000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269840Medicaid
ORI39121Medicare UPIN
OR132291Medicare ID - Type Unspecified