Healthcare Provider Details

I. General information

NPI: 1144297821
Provider Name (Legal Business Name): JONATHAN BRUCE JUNKIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 US HIGHWAY 51 BYP W
DYERSBURG TN
38024-1935
US

IV. Provider business mailing address

540 E STATE HIGHWAY 239
BLYTHEVILLE AR
72315-8808
US

V. Phone/Fax

Practice location:
  • Phone: 731-286-1271
  • Fax: 731-286-0019
Mailing address:
  • Phone: 910-750-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2987
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2987
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9318
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: