MEDICARE: DR. JONATHAN PAUL OUELLETTE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN20431	FL

General Provider Information

NPI Number	:	1215220843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN PAUL OUELLETTE DMD

Provider Business Mailing Address
First Line	:	210 LORAINE DR
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-3307
Country	:	US
Telephone Number	:	407-862-7000
Fax Number	:	407-788-1452

Provider Business Practice Location Address
First Line	:	210 LORAINE DR
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-3307
Country	:	US
Telephone Number	:	407-862-7000
Fax Number	:	407-788-1452

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	12/27/2016

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