Healthcare Provider Details

I. General information

NPI: 1144224478
Provider Name (Legal Business Name): JASON G BOUTWELL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 CHAPEL HILL RD SUITE A
DOUGLASVILLE GA
30135-1748
US

IV. Provider business mailing address

3009 CHAPEL HILL RD SUITE A
DOUGLASVILLE GA
30135-1748
US

V. Phone/Fax

Practice location:
  • Phone: 770-942-8288
  • Fax: 770-942-9121
Mailing address:
  • Phone: 770-942-8288
  • Fax: 770-942-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number011683
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: