Provider Demographics
NPI:1184455784
Name:AGOS, JONATHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:AGOS
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 1:16 JEFFREY LN
Mailing Address - Street 2:
Mailing Address - City:MERCERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1163
Mailing Address - Country:US
Mailing Address - Phone:609-649-4697
Mailing Address - Fax:
Practice Address - Street 1:1100 S BROAD ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08611-1410
Practice Address - Country:US
Practice Address - Phone:609-393-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI03059700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist