Healthcare Provider Details

I. General information

NPI: 1134403009
Provider Name (Legal Business Name): JASON C LACOURSE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 MONROE AVE
FORT EUSTIS VA
23604-5005
US

IV. Provider business mailing address

669 MONROE AVE
FORT EUSTIS VA
23604-5005
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-8017
  • Fax:
Mailing address:
  • Phone: 757-314-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7735000-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: