Healthcare Provider Details

I. General information

NPI: 1043558984
Provider Name (Legal Business Name): JASON M ALLRED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 1ST ST SE
WADENA MN
56482-1561
US

IV. Provider business mailing address

91 PUTTER LN
WADENA MN
56482-8900
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-4431
  • Fax:
Mailing address:
  • Phone: 218-371-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT20
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: