Provider Demographics
NPI:1629147814
Name:CHOSTNER, JERRY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:CHOSTNER
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 1:2 SHEFFIELD PL
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-2046
Mailing Address - Country:US
Mailing Address - Phone:336-723-0073
Mailing Address - Fax:
Practice Address - Street 1:6301 STADIUM DR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8766
Practice Address - Country:US
Practice Address - Phone:336-766-9111
Practice Address - Fax:336-766-3941
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice