Provider Demographics
NPI:1306856356
Name:WILLINGHAM, JON YOUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:YOUNG
Last Name:WILLINGHAM
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 1:1804 COLE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-4043
Mailing Address - Country:US
Mailing Address - Phone:913-406-5142
Mailing Address - Fax:
Practice Address - Street 1:LA CLINICA MONUMENT DENTAL 2000 SIERRA ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518
Practice Address - Country:US
Practice Address - Phone:925-363-1256
Practice Address - Fax:925-356-2499
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS603191223G0001X
CA1000421223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice