Healthcare Provider Details

I. General information

NPI: 1114378999
Provider Name (Legal Business Name): JASON MACIK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 BREWER ST
ASHEBORO NC
27203
US

IV. Provider business mailing address

308 BREWER ST
ASHEBORO NC
27203-4896
US

V. Phone/Fax

Practice location:
  • Phone: 336-610-7000
  • Fax:
Mailing address:
  • Phone: 336-610-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-4756
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: