Provider Demographics
NPI:1144715293
Name:SHOLLY, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SHOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 6TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2618
Mailing Address - Country:US
Mailing Address - Phone:253-759-5437
Mailing Address - Fax:253-426-1836
Practice Address - Street 1:909 SLEATER KINNEY RD SE STE 3
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1103
Practice Address - Country:US
Practice Address - Phone:360-491-1414
Practice Address - Fax:360-628-8015
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE6085544122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist