Provider Demographics
NPI:1659447670
Name:DOUGLAS T JONAK DDS PA
Entity type:Organization
Organization Name:DOUGLAS T JONAK DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-757-2768
Mailing Address - Street 1:27367 BLUE LAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398
Mailing Address - Country:US
Mailing Address - Phone:763-856-5545
Mailing Address - Fax:
Practice Address - Street 1:800 MAIN ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434
Practice Address - Country:US
Practice Address - Phone:763-757-2768
Practice Address - Fax:763-757-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN95701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty