Provider Demographics
NPI:1801058276
Name:BLUNDELL, JASON BRIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:BRIAN
Last Name:BLUNDELL
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 1:2541 WHITTLER BR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-1875
Mailing Address - Country:US
Mailing Address - Phone:804-683-1562
Mailing Address - Fax:
Practice Address - Street 1:410 W BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7402
Practice Address - Country:US
Practice Address - Phone:813-531-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014121911223G0001X, 1223S0112X
FL231751223S0112X
FLDN231751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice