Healthcare Provider Details

I. General information

NPI: 1396952297
Provider Name (Legal Business Name): JONATHAN R DEJONG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 KENYON RD STE 120
FORT DODGE IA
50501-5746
US

IV. Provider business mailing address

804 KENYON RD STE 120
FORT DODGE IA
50501-5746
US

V. Phone/Fax

Practice location:
  • Phone: 515-576-8727
  • Fax: 515-576-7076
Mailing address:
  • Phone: 515-576-8727
  • Fax: 515-576-7076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number08428
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: