Provider Demographics
NPI:1801374715
Name:DISMUKE, JONATHAN JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAMES
Last Name:DISMUKE
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 1:36000 DARNALL LOOP RM 1048
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5095
Mailing Address - Country:US
Mailing Address - Phone:254-287-2705
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP RM 1048
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010128122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist