Provider Demographics
NPI:1366762031
Name:MAHONEY, JASON (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:TX
Mailing Address - Zip Code:79521-0438
Mailing Address - Country:US
Mailing Address - Phone:940-864-3485
Mailing Address - Fax:940-864-3653
Practice Address - Street 1:601 S 1ST ST
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:TX
Practice Address - Zip Code:79521-5635
Practice Address - Country:US
Practice Address - Phone:940-864-3485
Practice Address - Fax:940-864-3653
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101881223G0001X
TX284641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice