Provider Demographics
NPI:1306912621
Name:ETHERTON, JASON ANTHONY (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANTHONY
Last Name:ETHERTON
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 1:6 MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854-3665
Mailing Address - Country:US
Mailing Address - Phone:334-756-4178
Mailing Address - Fax:334-756-5884
Practice Address - Street 1:6 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3665
Practice Address - Country:US
Practice Address - Phone:334-756-4178
Practice Address - Fax:334-756-5884
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL48401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU85141Medicare ID - Type Unspecified