Healthcare Provider Details

I. General information

NPI: 1093854481
Provider Name (Legal Business Name): DR. JASON D BARLOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8595 COLLEGE PKWY SUITE B-5
FORT MYERS FL
33919-5191
US

IV. Provider business mailing address

15241 CORTONA WAY
NAPLES FL
34120-0673
US

V. Phone/Fax

Practice location:
  • Phone: 239-433-0921
  • Fax:
Mailing address:
  • Phone: 239-776-4633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN15803
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: