Provider Demographics
NPI:1619194834
Name:MACLEAN, JONATHAN
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:MACLEAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 VINTAGE WAY
Mailing Address - Street 2:SUITE K23
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-5014
Mailing Address - Country:US
Mailing Address - Phone:415-898-5100
Mailing Address - Fax:
Practice Address - Street 1:208 VINTAGE WAY
Practice Address - Street 2:SUITE K23
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5014
Practice Address - Country:US
Practice Address - Phone:415-898-5100
Practice Address - Fax:415-898-0226
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA466411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680473534OtherTIN