Provider Demographics
NPI:1457890071
Name:HAVENER, JONATHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:HAVENER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 LIVE OAK ST APT 129
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2747 N O CONNOR RD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-5650
Practice Address - Country:US
Practice Address - Phone:972-871-7681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32680122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist