Provider Demographics
NPI:1871781625
Name:EVISON, JASON WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:WILLIAM
Last Name:EVISON
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 1:1621 TONGASS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-6013
Mailing Address - Country:US
Mailing Address - Phone:907-225-8228
Mailing Address - Fax:
Practice Address - Street 1:1621 TONGASS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6013
Practice Address - Country:US
Practice Address - Phone:907-225-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1235122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0034Medicaid
AK1235OtherSTATE LICENSE