Provider Demographics
NPI:1669704300
Name:BULTEMA, JONATHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:BULTEMA
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 1:594 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:HORACE
Mailing Address - State:ND
Mailing Address - Zip Code:58047-4640
Mailing Address - Country:US
Mailing Address - Phone:701-552-6001
Mailing Address - Fax:701-781-8056
Practice Address - Street 1:594 MAIN ST N
Practice Address - Street 2:
Practice Address - City:HORACE
Practice Address - State:ND
Practice Address - Zip Code:58047-4640
Practice Address - Country:US
Practice Address - Phone:701-552-6001
Practice Address - Fax:701-781-8056
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20461223G0001X
SDD1036122300000X
MN13339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1451030Medicaid