Provider Demographics
NPI:1619218799
Name:PATRICK, JONATHAN ROBERT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:PATRICK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24510 HIGHWAY 59 N STE 110
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2692
Mailing Address - Country:US
Mailing Address - Phone:281-608-7535
Mailing Address - Fax:281-608-7537
Practice Address - Street 1:24510 EASTEX FWY STE 110
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-2698
Practice Address - Country:US
Practice Address - Phone:281-608-7535
Practice Address - Fax:281-608-7537
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30790122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX357948401Medicaid
TX357948402Medicaid