Basic Information
| Provider Information | |||||||||
| NPI: | 1326408683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOV | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1830 160TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980082507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252793031 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1050 140TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253733000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2016 | ||||||||
| LastUpdateDate: | 07/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60728381 | WA | Y | Dental Providers | Dentist |
No ID Information.