Provider Demographics
NPI:1295189280
Name:BISHOP, JONATHAN (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BISHOP
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 1:455 WASHINGTON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-6105
Mailing Address - Country:US
Mailing Address - Phone:617-519-8500
Mailing Address - Fax:
Practice Address - Street 1:208 MAIN ST STE 116
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2502
Practice Address - Country:US
Practice Address - Phone:508-244-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-16
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18572601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty