MEDICARE: DR. JONATHAN J KOLON DDS

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	1223G0001X	General Practice Dentistry	4994088	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	201588686	OTHER	UT	FEIN

General Provider Information

NPI Number	:	1225239171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN J KOLON DDS

Provider Business Mailing Address
First Line	:	3176 SANTA CLARA DR
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765-5338
Country	:	US
Telephone Number	:	435-615-6819
Fax Number	:

Provider Business Practice Location Address
First Line	:	3176 SANTA CLARA DRIVE
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765
Country	:	US
Telephone Number	:	435-615-6819
Fax Number	:	435-658-0041

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

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	09/28/2020

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