Provider Demographics
NPI:1043458359
Name:SUTHERLAND, JON K (DDS)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:K
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-4705
Mailing Address - Country:US
Mailing Address - Phone:845-292-8022
Mailing Address - Fax:845-292-3153
Practice Address - Street 1:68 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-4705
Practice Address - Country:US
Practice Address - Phone:845-292-8022
Practice Address - Fax:845-292-3153
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0401431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice