Healthcare Provider Details

I. General information

NPI: 1497112049
Provider Name (Legal Business Name): JONATHAN DAVID RISNER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5521 BELLAIRE DR S
FORT WORTH TX
76109-8838
US

IV. Provider business mailing address

4902 TRAILHEAD BEND WAY APT 12305
FORT WORTH TX
76109-1654
US

V. Phone/Fax

Practice location:
  • Phone: 817-569-6633
  • Fax:
Mailing address:
  • Phone: 812-431-7758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number31757
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: