Provider Demographics
NPI:1144385659
Name:WOLLER, JONATHAN P (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:WOLLER
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 1:3535 COLLEGE RD
Mailing Address - Street 2:SUITE #205
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3722
Mailing Address - Country:US
Mailing Address - Phone:907-479-6747
Mailing Address - Fax:907-479-5786
Practice Address - Street 1:3535 COLLEGE RD
Practice Address - Street 2:SUITE #205
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3722
Practice Address - Country:US
Practice Address - Phone:907-479-6747
Practice Address - Fax:907-479-5786
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11967122300000X
AK1155122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist