Healthcare Provider Details

I. General information

NPI: 1508531666
Provider Name (Legal Business Name): JASON DONALD MECUM DHAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MILUK DR
COOS BAY OR
97420-7728
US

IV. Provider business mailing address

PO BOX 3190
COOS BAY OR
97420-0407
US

V. Phone/Fax

Practice location:
  • Phone: 541-888-9494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number18-TDT-02
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: