MEDICARE: DR. JASON K POTTER M.D., D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	MD25735	OR
2	174400000X	Specialist	M6345	TX
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	M6345	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467449207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON K POTTER M.D., D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 93982
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-0119
Country	:	US
Telephone Number	:	214-930-6588
Fax Number	:

Provider Business Practice Location Address
First Line	:	8220 WALNUT HILL LN
Second Line	:	SUITE 206
City	:	DALLAS
State	:	TX
Zip	:	75231-4427
Country	:	US
Telephone Number	:	214-930-6588
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	10/22/2008

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Directions to “ DR. JASON K POTTER M.D., D.D.S.” Practice Location

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