Provider Demographics
NPI:1912226895
Name:LILLY, JASON SCOTT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:SCOTT
Last Name:LILLY
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 1:2285 RUDOLPHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043
Mailing Address - Country:US
Mailing Address - Phone:931-552-3292
Mailing Address - Fax:931-552-3243
Practice Address - Street 1:2285 RUDOLPHTOWN RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-552-3292
Practice Address - Fax:931-552-3243
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN98471223S0112X
390200000X
TNTN98471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program