MEDICARE: DR. JONATHAN CHARLES WALDRON DMD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	9125	GA

General Provider Information

NPI Number	:	1962551093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN CHARLES WALDRON DMD PC

Provider Business Mailing Address
First Line	:	1020 DAVENPORT CIR
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4213
Country	:	US
Telephone Number	:	678-354-4009
Fax Number	:	770-509-2326

Provider Business Practice Location Address
First Line	:	3020 ROSWELL RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-4996
Country	:	US
Telephone Number	:	770-977-5547
Fax Number	:	770-509-2326

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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