Provider Demographics
NPI:1508152703
Name:WOOTEN, JONATHAN DAVIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVIS
Last Name:WOOTEN
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 1:4147 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3001
Mailing Address - Country:US
Mailing Address - Phone:614-263-0300
Mailing Address - Fax:
Practice Address - Street 1:4147 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3001
Practice Address - Country:US
Practice Address - Phone:614-263-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.3109122300000X
OH30-0236811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist