Provider Demographics
NPI:1790302180
Name:WILLIAMS, JONATHON LOGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:LOGAN
Last Name:WILLIAMS
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 1:1930 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1621
Mailing Address - Country:US
Mailing Address - Phone:540-989-1170
Mailing Address - Fax:
Practice Address - Street 1:175 MARKET RIDGE LN
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3260
Practice Address - Country:US
Practice Address - Phone:540-992-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014169561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice