MEDICARE: JONATHAN L BULLARD 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	1223G0001X	General Practice Dentistry	6964	SC
2	1223G0001X	General Practice Dentistry	DN014101	GA

General Provider Information

NPI Number	:	1578862777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN L BULLARD DMD

Provider Business Mailing Address
First Line	:	3702 WASHINGTON RD.
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30907-2848
Country	:	US
Telephone Number	:	706-863-5337
Fax Number	:	706-855-8249

Provider Business Practice Location Address
First Line	:	3702 WASHINGTON RD.
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30907-2848
Country	:	US
Telephone Number	:	706-863-5337
Fax Number	:	706-855-8249

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

Provider Enumeration Date	:	03/28/2011
Last Update Date	:	10/22/2011

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Directions to “ JONATHAN L BULLARD DMD” Practice Location

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