Healthcare Provider Details

I. General information

NPI: 1538760947
Provider Name (Legal Business Name): JEVON K RHULE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 WASHINGTON ST UNIT B523
JAMAICA PLAIN MA
02130-2960
US

IV. Provider business mailing address

3611 WASHINGTON ST UNIT B523
JAMAICA PLAIN MA
02130-2960
US

V. Phone/Fax

Practice location:
  • Phone: 754-234-2030
  • Fax:
Mailing address:
  • Phone: 754-234-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1858857
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: