Provider Demographics
NPI:1124432638
Name:FOREMAN, JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:FOREMAN
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 1:2916 CROSSING CT
Mailing Address - Street 2:SUITE #C
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6199
Mailing Address - Country:US
Mailing Address - Phone:217-352-5809
Mailing Address - Fax:217-352-5812
Practice Address - Street 1:2916 CROSSING CT
Practice Address - Street 2:SUITE #C
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6199
Practice Address - Country:US
Practice Address - Phone:217-352-5809
Practice Address - Fax:217-352-5812
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029690122300000X
IL0210025801223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist