MEDICARE: JASON JAMES AUGUSTINE DDS MS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D5240	AZ

General Provider Information

NPI Number	:	1114034188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON JAMES AUGUSTINE DDS MS PC

Provider Business Mailing Address
First Line	:	4025 W BELL RD
Second Line	:	SUITE 4
City	:	PHOENIX
State	:	AZ
Zip	:	85053-2748
Country	:	US
Telephone Number	:	602-978-6910
Fax Number	:	602-978-6920

Provider Business Practice Location Address
First Line	:	4025 W BELL RD
Second Line	:	SUITE 4
City	:	PHOENIX
State	:	AZ
Zip	:	85053-2748
Country	:	US
Telephone Number	:	602-978-6910
Fax Number	:	602-978-6910

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	07/08/2007

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