Provider Demographics
NPI:1649668898
Name:STEVENS, JASON M (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:STEVENS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 MACLAND RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-5190
Mailing Address - Country:US
Mailing Address - Phone:770-445-1081
Mailing Address - Fax:770-445-7737
Practice Address - Street 1:2176 MACLAND RD
Practice Address - Street 2:SUITE B
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-5190
Practice Address - Country:US
Practice Address - Phone:770-445-1081
Practice Address - Fax:770-445-7737
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012439122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist