Provider Demographics
NPI:1043866338
Name:JRL DENTAL DBA GRACE DENTAL CARE
Entity Type:Organization
Organization Name:JRL DENTAL DBA GRACE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-784-6665
Mailing Address - Street 1:1628 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15081 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:CHELYAN
Practice Address - State:WV
Practice Address - Zip Code:25035
Practice Address - Country:US
Practice Address - Phone:304-595-3551
Practice Address - Fax:304-595-6822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty