Provider Demographics
NPI:1790943454
Name:WOODYARD, JONATHAN H (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:H
Last Name:WOODYARD
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 1:180 SPRING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8894
Mailing Address - Country:US
Mailing Address - Phone:502-938-7842
Mailing Address - Fax:
Practice Address - Street 1:3235 OLIVET CHURCH RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9545
Practice Address - Country:US
Practice Address - Phone:270-408-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 86461223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program