=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497942775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID T JONKE DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15640 MADISON AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-228-1012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15640 MADISON AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-228-1012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT
-----------------------------------------------------
Name | DR. DAVID THOMAS JONKE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 216-228-1012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13691
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------