Provider Demographics
NPI:1306825732
Name:GAMBREL, JASON OTTO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:OTTO
Last Name:GAMBREL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 IVAL JAMES BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8026
Mailing Address - Country:US
Mailing Address - Phone:859-626-9851
Mailing Address - Fax:859-626-9854
Practice Address - Street 1:1018 IVAL JAMES BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8026
Practice Address - Country:US
Practice Address - Phone:859-626-9851
Practice Address - Fax:859-626-9854
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7992122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60004066Medicaid
KY45004025Medicaid