Provider Demographics
NPI:1104987171
Name:PITTMAN, JASON BLAINE (DDS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BLAINE
Last Name:PITTMAN
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 1:401 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-3588
Mailing Address - Country:US
Mailing Address - Phone:423-968-4422
Mailing Address - Fax:423-968-3477
Practice Address - Street 1:401 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-3588
Practice Address - Country:US
Practice Address - Phone:423-968-4422
Practice Address - Fax:423-968-3477
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS82391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice