Healthcare Provider Details

I. General information

NPI: 1447733407
Provider Name (Legal Business Name): JONATHAN MICHAEL DREW DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 11/19/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 9TH ST
LAKEPORT CA
95453-4320
US

IV. Provider business mailing address

3240 FINCH DR
SAN JOSE CA
95117-3512
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-5390
  • Fax:
Mailing address:
  • Phone: 408-314-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number102563
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: