Provider Demographics
NPI:1023040789
Name:RAY, JASON R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:RAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-3546
Mailing Address - Country:US
Mailing Address - Phone:985-446-8037
Mailing Address - Fax:985-447-4648
Practice Address - Street 1:698 E 1ST ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-3546
Practice Address - Country:US
Practice Address - Phone:985-446-8037
Practice Address - Fax:985-447-4648
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA43051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAA2078OtherBLUE CROSS BLUE SHIELD
LA847061OtherUS GOV UNITED CONCORDIA