Provider Demographics
NPI:1720092521
Name:ECKHARDT, JON J (DDS, MSD, ABO)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:J
Last Name:ECKHARDT
Suffix:
Gender:M
Credentials:DDS, MSD, ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 VAN GUNDY DR STE C
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1179
Mailing Address - Country:US
Mailing Address - Phone:419-636-5918
Mailing Address - Fax:419-636-0752
Practice Address - Street 1:201 VAN GUNDY DR
Practice Address - Street 2:STE. C
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1178
Practice Address - Country:US
Practice Address - Phone:419-636-5918
Practice Address - Fax:419-636-0752
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH210181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2412900Medicaid