Provider Demographics
NPI:1780996801
Name:LUE YEN, JASON THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:THOMAS
Last Name:LUE YEN
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:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-0459
Mailing Address - Country:US
Mailing Address - Phone:706-788-3234
Mailing Address - Fax:
Practice Address - Street 1:226 STEVEN B TANGER BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-3571
Practice Address - Country:US
Practice Address - Phone:706-423-9291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN191491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice