Provider Demographics
NPI:1477000164
Name:JELMINI, JONATHAN (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:JELMINI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG188470208600000X
ORD10527122300000X
TX38275122300000X, 1223S0112X
TXT6917208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No122300000XDental ProvidersDentist