Healthcare Provider Details

I. General information

NPI: 1730792359
Provider Name (Legal Business Name): JASON ABRAHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4243 AMBASSADOR CAFFERY PKWY STE 118
LAFAYETTE LA
70508-7268
US

IV. Provider business mailing address

3815 TIMBERS EDGE LN
GLENVIEW IL
60025-1480
US

V. Phone/Fax

Practice location:
  • Phone: 337-422-3587
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019032886
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number600136815
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7634
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: