Provider Demographics
NPI:1336394568
Name:BACON, JASON T (DDS)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:T
Last Name:BACON
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 1:201 S. ROGERS RD.
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-2608
Mailing Address - Country:US
Mailing Address - Phone:972-213-0045
Mailing Address - Fax:972-600-8465
Practice Address - Street 1:201 S. ROGERS RD.
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75060-2608
Practice Address - Country:US
Practice Address - Phone:972-213-0045
Practice Address - Fax:972-600-8465
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX243811223G0001X
CA578781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice