Healthcare Provider Details

I. General information

NPI: 1578899829
Provider Name (Legal Business Name): JASUN MAHAFFEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 PARK AVE
WORCESTER MA
01610-1025
US

IV. Provider business mailing address

16 ARCADE UNIT 198747
NASHVILLE TN
37219-1994
US

V. Phone/Fax

Practice location:
  • Phone: 508-798-6565
  • Fax: 508-798-6687
Mailing address:
  • Phone: 615-750-0343
  • Fax: 615-986-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDL10614
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN1855938
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: