Healthcare Provider Details

I. General information

NPI: 1477576106
Provider Name (Legal Business Name): JASON ROGER IZZI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 SMITH ST
NORTH PROVIDENCE RI
02911-3340
US

IV. Provider business mailing address

1351 SMITH ST
NORTH PROVIDENCE RI
02911-3340
US

V. Phone/Fax

Practice location:
  • Phone: 401-353-2045
  • Fax: 401-354-8488
Mailing address:
  • Phone: 401-353-2045
  • Fax: 401-354-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2581
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: