Provider Demographics
NPI:1902270705
Name:DALE, JASON (DMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DALE
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 1:438 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3270
Mailing Address - Country:US
Mailing Address - Phone:954-683-8153
Mailing Address - Fax:
Practice Address - Street 1:1928 COMMERCE LN STE 1
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5598
Practice Address - Country:US
Practice Address - Phone:561-210-7333
Practice Address - Fax:561-529-2618
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21447122300000X
FLDN214471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024664900Medicaid