Healthcare Provider Details

I. General information

NPI: 1205125796
Provider Name (Legal Business Name): JASON KILLIAN WITTENMYER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JASON KILLIAN WITTENMYER DMD

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 CHADWICK WAY
TALLAHASSEE FL
32312-3774
US

IV. Provider business mailing address

1540 CHADWICK WAY
TALLAHASSEE FL
32312-3774
US

V. Phone/Fax

Practice location:
  • Phone: 850-617-9155
  • Fax:
Mailing address:
  • Phone: 502-617-9155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDCT5
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8022
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: