MEDICARE: JONATHAN R ABRAHAM, 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	3622	WV

General Provider Information

NPI Number	:	1316330210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN R ABRAHAM, DDS

Provider Business Mailing Address
First Line	:	3814 MACCORKLE AVE SE
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-1528
Country	:	US
Telephone Number	:	304-925-0322
Fax Number	:	304-925-2337

Provider Business Practice Location Address
First Line	:	3814 MACCORKLE AVE SE
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-1528
Country	:	US
Telephone Number	:	304-925-0322
Fax Number	:	304-925-2337

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. JONATHAN ROBERT ABRAHAM
Credential	:	DDS
Telephone Number	:	304-925-0322

Provider Enumeration Date	:	03/17/2015
Last Update Date	:	03/17/2015

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