Provider Demographics
NPI:1275123788
Name:MASON, JARVITZ
Entity Type:Individual
Prefix:
First Name:JARVITZ
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JARVITZ
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDA
Mailing Address - Street 1:116 HOVEY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3207
Mailing Address - Country:US
Mailing Address - Phone:323-439-0167
Mailing Address - Fax:
Practice Address - Street 1:116 HOVEY AVE
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3207
Practice Address - Country:US
Practice Address - Phone:323-439-0167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96019126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant