MEDICARE: DR. JASON G BOUTWELL DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	011683	GA

General Provider Information

NPI Number	:	1144224478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON G BOUTWELL DMD

Provider Business Mailing Address
First Line	:	3009 CHAPEL HILL RD
Second Line	:	SUITE A
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30135-1748
Country	:	US
Telephone Number	:	770-942-8288
Fax Number	:	770-942-9121

Provider Business Practice Location Address
First Line	:	3009 CHAPEL HILL RD
Second Line	:	SUITE A
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30135-1748
Country	:	US
Telephone Number	:	770-942-8288
Fax Number	:	770-942-9121

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	09/03/2015

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