Healthcare Provider Details

I. General information

NPI: 1861002719
Provider Name (Legal Business Name): JONATTAN EDUARDO ANGULO-OCHOA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD STE 155
DETROIT MI
48236-2152
US

IV. Provider business mailing address

22201 MOROSS RD STE 155
DETROIT MI
48236-2152
US

V. Phone/Fax

Practice location:
  • Phone: 313-499-4929
  • Fax: 313-499-4953
Mailing address:
  • Phone: 313-499-4929
  • Fax: 313-499-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number5315214666
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2952000716
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number5315214665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: