=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619218799
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN ROBERT PATRICK D.D.S., M.S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2013
-----------------------------------------------------
Last Update Date | 11/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24510 EASTEX FWY STE 110
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-2698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-608-7535
-----------------------------------------------------
Fax | 281-608-7537
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24510 HIGHWAY 59 N STE 110
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-2692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-608-7535
-----------------------------------------------------
Fax | 281-608-7537
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30790
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 30790
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------