=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487947560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN JAMES KOENIGSKNECHT DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2011
-----------------------------------------------------
Last Update Date | 05/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 E CASS ST
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48879-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-224-2319
-----------------------------------------------------
Fax | 989-224-2144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 E CASS ST
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48879-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-224-2319
-----------------------------------------------------
Fax | 989-224-2144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901020405
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------