Provider Demographics
NPI:1033222583
Name:SUDOL, JONATHAN C (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:C
Last Name:SUDOL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 COLLEGE HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077-9260
Mailing Address - Country:US
Mailing Address - Phone:413-642-5250
Mailing Address - Fax:413-831-6366
Practice Address - Street 1:664 COLLEGE HWY
Practice Address - Street 2:
Practice Address - City:SOUTHWICK
Practice Address - State:MA
Practice Address - Zip Code:01077-9260
Practice Address - Country:US
Practice Address - Phone:413-642-5250
Practice Address - Fax:413-831-6366
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH32651223S0112X
MA204611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE6662Medicare ID - Type Unspecified
U90013Medicare UPIN