Provider Demographics
NPI:1245382936
Name:MULLEN, JASON WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:WAYNE
Last Name:MULLEN
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 1:533 WATAUGA ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1969
Mailing Address - Country:US
Mailing Address - Phone:919-260-0660
Mailing Address - Fax:
Practice Address - Street 1:100 PINECROFT DR.
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520
Practice Address - Country:US
Practice Address - Phone:919-585-7321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903842Medicaid