Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | M6345 | TX |
N | 204E00000X | Oral & Maxillofacial Surgeon | MD25735 | OR |
NPI | 1467449207 |
---|---|
Provider Name | Dr. Jason K Potter |
First Address | Southlake, TX 76092-0119 |
Second Address | Dallas, TX 75231-4427 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2005 |
Last Update Date | 22/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
269840 | (05) | OR |
I39121 | (02) | OR |