Provider Demographics
NPI:1902031453
Name:MCILVAIN, JASON JOHNSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:JOHNSON
Last Name:MCILVAIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 MT VERNON RD
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-5617
Mailing Address - Country:US
Mailing Address - Phone:859-576-5910
Mailing Address - Fax:
Practice Address - Street 1:111 KY HIGHWAY 32 W STE 2
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-8574
Practice Address - Country:US
Practice Address - Phone:859-234-9944
Practice Address - Fax:859-234-9942
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8719122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice