Healthcare Provider Details

I. General information

NPI: 1205147444
Provider Name (Legal Business Name): JASON W. EVISON, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 TONGASS AVE SUITE 103
KETCHIKAN AK
99901-6013
US

IV. Provider business mailing address

1621 TONGASS AVE SUITE 103
KETCHIKAN AK
99901-6013
US

V. Phone/Fax

Practice location:
  • Phone: 907-225-8228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1235
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON W EVISON
Title or Position: DIRECTOR
Credential: DDS
Phone: 907-225-8228