Provider Demographics
NPI:1477629046
Name:BACKER, JONATHAN E (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:E
Last Name:BACKER
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 1:1551 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-2241
Mailing Address - Country:US
Mailing Address - Phone:541-942-8437
Mailing Address - Fax:541-942-1350
Practice Address - Street 1:1551 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2241
Practice Address - Country:US
Practice Address - Phone:541-942-8437
Practice Address - Fax:541-942-1350
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7805122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist