Provider Demographics
NPI:1073185336
Name:CHRISIAN, JONATHAN LOGAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LOGAN
Last Name:CHRISIAN
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 1:311 PETE PHILLIPS DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8821
Mailing Address - Country:US
Mailing Address - Phone:912-537-7048
Mailing Address - Fax:912-537-7058
Practice Address - Street 1:311 PETE PHILLIPS DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8821
Practice Address - Country:US
Practice Address - Phone:912-537-7048
Practice Address - Fax:912-537-7058
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1224261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice