MEDICARE: DR. JASON EHTESSABIAN 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	122300000X	Dentist	9520	CO

General Provider Information

NPI Number	:	1770776809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON EHTESSABIAN D.D.S.

Provider Business Mailing Address
First Line	:	3740 DACORO LN
Second Line	:	SUITE 140
City	:	CASTLE ROCK
State	:	CO
Zip	:	80109-2503
Country	:	US
Telephone Number	:	303-688-6630
Fax Number	:	303-663-6534

Provider Business Practice Location Address
First Line	:	3740 DACORO LN
Second Line	:	SUITE 140
City	:	CASTLE ROCK
State	:	CO
Zip	:	80109-2503
Country	:	US
Telephone Number	:	303-688-6630
Fax Number	:	303-663-6534

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

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	08/31/2016

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