Provider Demographics
NPI:1265167522
Name:JONATHAN OUDIN, DDS, LLC
Entity type:Organization
Organization Name:JONATHAN OUDIN, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OUDIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-317-0521
Mailing Address - Street 1:1700 E BOGARD RD STE A201
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6569
Mailing Address - Country:US
Mailing Address - Phone:907-373-8455
Mailing Address - Fax:907-373-8456
Practice Address - Street 1:1700 E BOGARD RD STE A201
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6569
Practice Address - Country:US
Practice Address - Phone:907-373-8455
Practice Address - Fax:907-373-8456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1574946Medicaid