Provider Demographics
NPI:1245412162
Name:COOPER-LEAVITT, JONAH THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONAH
Middle Name:THOMAS
Last Name:COOPER-LEAVITT
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 1:512 MAIN ST E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-2369
Mailing Address - Country:US
Mailing Address - Phone:503-837-0512
Mailing Address - Fax:
Practice Address - Street 1:512 MAIN ST E
Practice Address - Street 2:SUITE 100
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361-2369
Practice Address - Country:US
Practice Address - Phone:503-837-0512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice