Provider Demographics
NPI:1235317744
Name:MADDATU, JONATHAN LORENZO (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LORENZO
Last Name:MADDATU
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 1:44841 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2311
Mailing Address - Country:US
Mailing Address - Phone:661-948-1655
Mailing Address - Fax:661-940-9636
Practice Address - Street 1:44841 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2311
Practice Address - Country:US
Practice Address - Phone:661-948-1655
Practice Address - Fax:661-940-9636
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice