Provider Demographics
NPI:1982835831
Name:KACZMARSKI, JONATHAN R (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:KACZMARSKI
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 1:991 W HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-6430
Mailing Address - Country:US
Mailing Address - Phone:704-853-5191
Mailing Address - Fax:704-671-1404
Practice Address - Street 1:890 SUMMIT CROSSING PL
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2192
Practice Address - Country:US
Practice Address - Phone:704-874-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC88441223P0221X
SC92011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry