Healthcare Provider Details

I. General information

NPI: 1851346613
Provider Name (Legal Business Name): JASON M MAILHOT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MAYFAIR RD SUITE #340
WAUWATOSA WI
53226-1309
US

IV. Provider business mailing address

4857 WHITE SWAN DR
WEST BEND WI
53095-9192
US

V. Phone/Fax

Practice location:
  • Phone: 414-259-0660
  • Fax: 414-259-0819
Mailing address:
  • Phone: 262-644-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6063-015
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN012270
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: