Provider Demographics
NPI:1235321589
Name:HAERTER, JONATHAN JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:JAMES
Last Name:HAERTER
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 1:227 MIDLAND AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8119
Mailing Address - Country:US
Mailing Address - Phone:970-927-5437
Mailing Address - Fax:
Practice Address - Street 1:227 MIDLAND AVE STE C3
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8119
Practice Address - Country:US
Practice Address - Phone:970-927-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8167122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO841554465OtherTAX ID NUMBER