Provider Demographics
NPI:1801151022
Name:GENTA, JASON PATRICK (DDS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:PATRICK
Last Name:GENTA
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 1:1250 W VAN BUREN ST
Mailing Address - Street 2:APT 707
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2820
Mailing Address - Country:US
Mailing Address - Phone:217-273-5518
Mailing Address - Fax:
Practice Address - Street 1:6749 N OSHKOSH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1162
Practice Address - Country:US
Practice Address - Phone:773-631-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028939122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist