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NPI Code Detail

MEDICARE: DR. JASON C PRIMAVERA D.D.S.

MEDICARE: DR. JASON C PRIMAVERA D.D.S.
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
11223S0112XOral and Maxillofacial Surgery (Dentist)018001817IL

General Provider Information

NPI Number : 1831487370
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JASON C PRIMAVERA D.D.S.
Provider Business Mailing Address
First Line : 6050 BRYNWOOD DR
Second Line :
City : ROCKFORD
State : IL
Zip : 61114-6579
Country : US
Telephone Number : 815-877-0694
Fax Number :
Provider Business Practice Location Address
First Line : 1901 W HARRISON ST
Second Line :
City : CHICAGO
State : IL
Zip : 60612-3714
Country : US
Telephone Number : 801-358-8697
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2011
Last Update Date : 08/24/2015

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