Provider Demographics
NPI:1245398890
Name:CALLAWAY, JONATHAN CLAYTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CLAYTON
Last Name:CALLAWAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:CLAYTON
Other - Last Name:CALLAWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS PC
Mailing Address - Street 1:2119 25TH STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201
Mailing Address - Country:US
Mailing Address - Phone:812-379-1341
Mailing Address - Fax:812-379-1343
Practice Address - Street 1:2119 25TH STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201
Practice Address - Country:US
Practice Address - Phone:812-379-1341
Practice Address - Fax:812-379-1343
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010253A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice