Provider Demographics
NPI:1659444776
Name:MOHORN, DAVID JASON (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JASON
Last Name:MOHORN
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 1:408 PARKWAY
Mailing Address - Street 2:SUITE A1
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1661
Mailing Address - Country:US
Mailing Address - Phone:336-663-8586
Mailing Address - Fax:877-710-7903
Practice Address - Street 1:408 PARKWAY
Practice Address - Street 2:SUITE A1
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1661
Practice Address - Country:US
Practice Address - Phone:336-663-8586
Practice Address - Fax:877-710-7903
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6366204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990074Medicaid
U71222Medicare UPIN
2428694Medicare ID - Type Unspecified