Provider Demographics
NPI:1104922194
Name:BOURNE, JASON R (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:BOURNE
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Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:815 STATE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4254
Mailing Address - Country:US
Mailing Address - Phone:360-659-0211
Mailing Address - Fax:360-658-0716
Practice Address - Street 1:815 STATE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4254
Practice Address - Country:US
Practice Address - Phone:360-659-0211
Practice Address - Fax:360-658-0716
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WADE000096031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics