Provider Demographics
NPI:1578622908
Name:LEE, JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:LEE
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 1:4257 POINT LA VISTA RD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6247
Mailing Address - Country:US
Mailing Address - Phone:904-703-2236
Mailing Address - Fax:
Practice Address - Street 1:4257 POINT LA VISTA RD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-6247
Practice Address - Country:US
Practice Address - Phone:904-703-2236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP4771223S0112X
AZD75211223S0112X
FLDN185541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA461503733AMedicaid
FL0767638-00Medicaid
FLAG125ZMedicare PIN