Provider Demographics
NPI:1023307113
Name:MCCABE, JONATHAN COLIN (MD, DMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:COLIN
Last Name:MCCABE
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CHAUCER CT
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5600
Mailing Address - Country:US
Mailing Address - Phone:507-327-9574
Mailing Address - Fax:
Practice Address - Street 1:116 CHAUCER CT
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5600
Practice Address - Country:US
Practice Address - Phone:507-327-9574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN204001223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery