Provider Demographics
NPI:1750468047
Name:GAY, JASON W (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:W
Last Name:GAY
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:PO BOX 86
Mailing Address - Street 2:10 RIVER DRIVE
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336
Mailing Address - Country:US
Mailing Address - Phone:606-723-1000
Mailing Address - Fax:606-723-1039
Practice Address - Street 1:10 RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336
Practice Address - Country:US
Practice Address - Phone:606-723-1000
Practice Address - Fax:606-723-1039
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7138122300000X
KY36331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60071388Medicaid
KY45000452Medicaid