MEDICARE: JASON ANTONIO DENTAL CORPORATION

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

General Provider Information

NPI Number	:	1598425399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASON ANTONIO DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:	951-370-1529
Fax Number	:	951-384-2503

Provider Business Practice Location Address
First Line	:	28080 CLINTON KEITH RD STE 100
Second Line	:
City	:	MURRIETA
State	:	CA
Zip	:	92563-4553
Country	:	US
Telephone Number	:	951-370-1529
Fax Number	:	951-384-2503

Authorized Official
Title or Position	:	OWNER
Name	:	JASON C. ANTONIO I
Credential	:	DDS
Telephone Number	:	951-370-1529

Provider Enumeration Date	:	12/21/2021
Last Update Date	:	12/21/2021

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