Provider Demographics
NPI:1861002719
Name:ANGULO, JONATTAN EDUARDO (DDS)
Entity Type:Individual
Prefix:
First Name:JONATTAN
Middle Name:EDUARDO
Last Name:ANGULO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11900 E 12 MILE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3490
Mailing Address - Country:US
Mailing Address - Phone:586-582-7100
Mailing Address - Fax:586-582-6147
Practice Address - Street 1:11900 E 12 MILE RD STE 210
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3490
Practice Address - Country:US
Practice Address - Phone:586-582-7100
Practice Address - Fax:586-582-6147
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315214666204E00000X
MI5315214665204E00000X
MI2952000716204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery