Healthcare Provider Details

I. General information

NPI: 1558625376
Provider Name (Legal Business Name): JONATHAN DENTON DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E 1ST ST
BAY MINETTE AL
36507-4029
US

IV. Provider business mailing address

301 E 1ST ST
BAY MINETTE AL
36507-4029
US

V. Phone/Fax

Practice location:
  • Phone: 251-580-0979
  • Fax: 251-580-0971
Mailing address:
  • Phone: 251-580-0979
  • Fax: 251-580-0971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4502
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5776
License Number StateAL

VIII. Authorized Official

Name: DR. JONATHAN D. DENTON
Title or Position: OWNER
Credential: D.M.D.
Phone: 256-665-1937