Healthcare Provider Details

I. General information

NPI: 1225239171
Provider Name (Legal Business Name): JONATHAN J KOLON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 09/28/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3176 SANTA CLARA DRIVE
SANTA CLARA UT
84765
US

IV. Provider business mailing address

3176 SANTA CLARA DR
SANTA CLARA UT
84765-5338
US

V. Phone/Fax

Practice location:
  • Phone: 435-615-6819
  • Fax: 435-658-0041
Mailing address:
  • Phone: 435-615-6819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4994088
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: