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General NPI Number Information
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NPI Number | 1982744249
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Entity Type | Organization
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Legal Business Name | JONATHAN D EAGLE DDS PC
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 11/22/2023
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Provider Practice Location Address
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Address Line | 1750 GRAND RIDGE COURT NE SUITE 202
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City | GRAND RAPIDS
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State | MI
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Zip | 49525
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Country | US
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Telephone | 616-361-9330
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Fax | 616-361-7095
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Provider Business Mailing Address
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Address Line | 1750 GRAND RIDGE COURT NE SUITE 202
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City | GRAND RAPIDS
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State | MI
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Zip | 49525
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Country | US
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Telephone | 616-361-9330
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Fax | 616-361-7095
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHNATHAN D EAGLE
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Credential | DDS PC
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Telephone | 616-361-9330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901015645
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License Number State | MI
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