Provider Demographics
NPI:1336307636
Name:FABIAN, JONATHAN ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:FABIAN
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 1:405 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMING PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55917-1440
Mailing Address - Country:US
Mailing Address - Phone:507-583-2141
Mailing Address - Fax:507-583-7574
Practice Address - Street 1:405 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMING PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55917-1440
Practice Address - Country:US
Practice Address - Phone:507-583-2141
Practice Address - Fax:507-583-7574
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12523122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist