Provider Demographics
NPI:1396842209
Name:KOLOSIONEK, JERRY STANLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:STANLEY
Last Name:KOLOSIONEK
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 1:750 E WASHINGTON ST
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2196
Mailing Address - Country:US
Mailing Address - Phone:330-725-3837
Mailing Address - Fax:330-764-4065
Practice Address - Street 1:750 E WASHINGTON ST
Practice Address - Street 2:SUITE A-3
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2196
Practice Address - Country:US
Practice Address - Phone:330-725-3837
Practice Address - Fax:330-764-4065
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist