=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023040789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON R. RAY DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 698 E 1ST ST
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70301-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-446-8037
-----------------------------------------------------
Fax | 985-447-4648
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 698 E 1ST ST
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70301-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-446-8037
-----------------------------------------------------
Fax | 985-447-4648
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4305
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------