Provider Demographics
NPI:1760144042
Name:FUNTANILLA, JONATHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:FUNTANILLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-7049 ELELE ST UNIT 14
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-3308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 HEARD STREET
Practice Address - Street 2:BUILDING 556
Practice Address - City:SCHOFIELD BARRACKS
Practice Address - State:HI
Practice Address - Zip Code:96857
Practice Address - Country:US
Practice Address - Phone:808-433-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011205122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD011205OtherDENTAL LICENSE