Provider Demographics
NPI:1538760947
Name:RHULE, JEVON K
Entity type:Individual
Prefix:
First Name:JEVON
Middle Name:K
Last Name:RHULE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 WASHINGTON ST UNIT B523
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2960
Mailing Address - Country:US
Mailing Address - Phone:754-234-2030
Mailing Address - Fax:
Practice Address - Street 1:3611 WASHINGTON ST UNIT B523
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2960
Practice Address - Country:US
Practice Address - Phone:754-234-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty