Provider Demographics
NPI:1417028531
Name:WALTNER, JONATHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:WALTNER
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 1:1953 51ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1345
Mailing Address - Country:US
Mailing Address - Phone:718-687-6255
Mailing Address - Fax:
Practice Address - Street 1:300 8TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3068
Practice Address - Country:US
Practice Address - Phone:718-499-5323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0508351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02606040Medicaid