Provider Demographics
NPI:1851346613
Name:MAILHOT, JASON M (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:MAILHOT
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 1:4857 WHITE SWAN DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9192
Mailing Address - Country:US
Mailing Address - Phone:262-644-0960
Mailing Address - Fax:
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE #340
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-259-0660
Practice Address - Fax:414-259-0819
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6063-0151223P0300X
GADN0122701223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG0219Medicaid