Provider Demographics
NPI:1023051257
Name:DAVIS, JONATHAN MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARK
Last Name:DAVIS
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 1:1410 HIGHLAND AVE.
Mailing Address - Street 2:#203
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492
Mailing Address - Country:US
Mailing Address - Phone:781-444-2669
Mailing Address - Fax:
Practice Address - Street 1:1410 HIGHLAND AVE.
Practice Address - Street 2:#203
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492
Practice Address - Country:US
Practice Address - Phone:781-444-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA153571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice