Healthcare Provider Details

I. General information

NPI: 1932515616
Provider Name (Legal Business Name): JONATHAN COULON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N GARFIELD ST SUITE 220
MIDLAND TX
79705-6400
US

IV. Provider business mailing address

3000 N GARFIELD ST SUITE 220
MIDLAND TX
79705-6400
US

V. Phone/Fax

Practice location:
  • Phone: 432-683-5313
  • Fax: 432-683-8195
Mailing address:
  • Phone: 432-683-5313
  • Fax: 432-683-8195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30078
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: