=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477000164
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN JELMINI DDS, MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2016
-----------------------------------------------------
Last Update Date | 07/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3181 SW SAM JACKSON PARK RD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-494-8916
-----------------------------------------------------
Fax | 503-494-6783
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3181 SW SAM JACKSON PARK RD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-494-8916
-----------------------------------------------------
Fax | 503-494-6783
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D10527
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | MD219104
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------