Provider Demographics
NPI:1831395086
Name:DAVIS, JASON J (DMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:DAVIS
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:PO BOX 5632
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-5632
Mailing Address - Country:US
Mailing Address - Phone:864-583-3717
Mailing Address - Fax:864-573-6067
Practice Address - Street 1:150 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-3364
Practice Address - Country:US
Practice Address - Phone:864-583-3717
Practice Address - Fax:864-573-6067
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC929839Medicaid