Provider Demographics
NPI:1104845817
Name:LIDDELL, JONATHAN C (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:LIDDELL
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 1:702 E SOUTH TEMPLE STE 209
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1795
Mailing Address - Country:US
Mailing Address - Phone:801-359-8282
Mailing Address - Fax:801-359-8902
Practice Address - Street 1:702 E SOUTH TEMPLE STE 209
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1795
Practice Address - Country:US
Practice Address - Phone:801-359-8282
Practice Address - Fax:801-359-8902
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5122081-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist