Provider Demographics
NPI:1407159775
Name:JONATHAN P WOLLER D.M.D. PC
Entity Type:Organization
Organization Name:JONATHAN P WOLLER D.M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:WOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DM D
Authorized Official - Phone:907-479-6747
Mailing Address - Street 1:3535 COLLEGE RD
Mailing Address - Street 2:SUITE #205
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3722
Mailing Address - Country:US
Mailing Address - Phone:907-479-6747
Mailing Address - Fax:907-479-5786
Practice Address - Street 1:3535 COLLEGE RD
Practice Address - Street 2:SUITE #205
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3722
Practice Address - Country:US
Practice Address - Phone:907-479-6747
Practice Address - Fax:907-479-5786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1155122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty