Provider Demographics
NPI:1134283252
Name:NITISUSANTA, JONATHAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:NITISUSANTA
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 1:10048 BRANDON CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-3714
Mailing Address - Country:US
Mailing Address - Phone:407-877-9003
Mailing Address - Fax:
Practice Address - Street 1:2704 REW CIR
Practice Address - Street 2:SUITE103
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-2994
Practice Address - Country:US
Practice Address - Phone:407-877-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13138122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist