MEDICARE: DR. JONATHAN M COPELAND D.D.S.

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	2009013176	MO

General Provider Information

NPI Number	:	1972832715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN M COPELAND D.D.S.

Provider Business Mailing Address
First Line	:	16545 WILLOW GLEN DR
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1748
Country	:	US
Telephone Number	:	636-273-5866
Fax Number	:	636-273-5349

Provider Business Practice Location Address
First Line	:	2426 TAYLOR RD
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63040-1222
Country	:	US
Telephone Number	:	636-273-5866
Fax Number	:	636-273-5349

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

Provider Enumeration Date	:	12/07/2009
Last Update Date	:	08/29/2013

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