Provider Demographics
NPI:1205043809
Name:WINDOM, JON (DDS)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:WINDOM
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 1:105 HERITAGE CIR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4208
Mailing Address - Country:US
Mailing Address - Phone:386-673-1257
Mailing Address - Fax:
Practice Address - Street 1:1081 A1A BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6733
Practice Address - Country:US
Practice Address - Phone:904-471-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN146861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice