Healthcare Provider Details

I. General information

NPI: 1831539188
Provider Name (Legal Business Name): JONATHAN MIODOWNIK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24764 SOUTHFIELD RD
SOUTHFIELD MI
48075-2715
US

IV. Provider business mailing address

44405 WOODWARD AVE MERCY DENTAL CENTER
PONTIAC MI
48341-5023
US

V. Phone/Fax

Practice location:
  • Phone: 248-557-2618
  • Fax:
Mailing address:
  • Phone: 248-858-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021005
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: