Provider Demographics
NPI:1164653895
Name:MCGONEGLE, JASON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:MCGONEGLE
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 1:122 CIVIC CENTER DR STE 105
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-6056
Mailing Address - Country:US
Mailing Address - Phone:760-726-0281
Mailing Address - Fax:
Practice Address - Street 1:122 CIVIC CENTER DR STE 105
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-6056
Practice Address - Country:US
Practice Address - Phone:760-726-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65178122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0190883OtherDEPARTMENT OF LABOR AND INDUSTRIES