Provider Demographics
NPI:1508942467
Name:GUMP, JASON GREGORY (DDS,PLLC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:GREGORY
Last Name:GUMP
Suffix:
Gender:M
Credentials:DDS,PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:RIVESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26588-0100
Mailing Address - Country:US
Mailing Address - Phone:304-278-5900
Mailing Address - Fax:304-278-5913
Practice Address - Street 1:176 MONROE AVE
Practice Address - Street 2:
Practice Address - City:RIVESVILLE
Practice Address - State:WV
Practice Address - Zip Code:26588
Practice Address - Country:US
Practice Address - Phone:304-278-5900
Practice Address - Fax:304-278-5913
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7800065-000Medicaid