Provider Demographics
NPI:1326327727
Name:STATESON, JONATHAN YRISARRI (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:YRISARRI
Last Name:STATESON
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 1:1611 MEREMONT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5391
Mailing Address - Country:US
Mailing Address - Phone:210-727-5350
Mailing Address - Fax:
Practice Address - Street 1:968 1ST INFANTRY DIVISION RD
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5210
Practice Address - Country:US
Practice Address - Phone:502-624-6158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26564122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist