Provider Demographics
NPI:1811993819
Name:GASS, JEDIDIAH R SR (DDS, MSD, PC)
Entity type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:R
Last Name:GASS
Suffix:SR
Gender:M
Credentials:DDS, MSD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:992 COUNTRY CLUB RD
Mailing Address - Street 2:STE 102
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6023
Mailing Address - Country:US
Mailing Address - Phone:541-687-1161
Mailing Address - Fax:541-344-9188
Practice Address - Street 1:992 COUNTRY CLUB RD
Practice Address - Street 2:STE 102
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6023
Practice Address - Country:US
Practice Address - Phone:541-687-1161
Practice Address - Fax:541-344-9188
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
ORD78661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics