Provider Demographics
NPI:1053378620
Name:BULLOCK, JASON SCOTT (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:SCOTT
Last Name:BULLOCK
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:BLDG 38717 38TH STREET
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5660
Mailing Address - Country:US
Mailing Address - Phone:706-787-6927
Mailing Address - Fax:706-787-2082
Practice Address - Street 1:BLDG 38717 38TH STREET
Practice Address - Street 2:USA DENTAL ACTIVITY
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5660
Practice Address - Country:US
Practice Address - Phone:706-787-6927
Practice Address - Fax:706-787-2082
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist