Provider Demographics
NPI:1053737049
Name:SPEARS, JASON (DDS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SPEARS
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:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-1357
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-226-4650
Practice Address - Street 1:4300 KINGS HWY
Practice Address - Street 2:SUITE 500
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2917
Practice Address - Country:US
Practice Address - Phone:239-344-2337
Practice Address - Fax:941-629-2365
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 205141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011672400Medicaid