Provider Demographics
NPI:1922266915
Name:CALDERON, JONATHAN TREVINO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:TREVINO
Last Name:CALDERON
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 1:215 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-2925
Mailing Address - Country:US
Mailing Address - Phone:321-773-7552
Mailing Address - Fax:
Practice Address - Street 1:215 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-2925
Practice Address - Country:US
Practice Address - Phone:321-773-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 18262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist