=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659447670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOUGLAS T JONAK DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 MAIN ST NE
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-757-2768
-----------------------------------------------------
Fax | 763-757-8038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27367 BLUE LAKE DR NW
-----------------------------------------------------
City | ZIMMERMAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-856-5545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. LYDIA JONAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-757-2768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 9570
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------