Provider Demographics
NPI:1093329260
Name:SOETANDIO, JONATHAN CHU-MING (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CHU-MING
Last Name:SOETANDIO
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 1:215 S LOOP 336 W
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5510 E 41ST ST STE C
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6009
Practice Address - Country:US
Practice Address - Phone:918-641-4635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7387122300000X
TX379171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist