Provider Demographics
NPI:1720261126
Name:EAGLE, JONATHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:EAGLE
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 1:1750 GRAND RIDGE COURT NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-361-9330
Mailing Address - Fax:616-361-7095
Practice Address - Street 1:1750 GRAND RIDGE COURT NE
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-361-9330
Practice Address - Fax:616-361-7095
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID156450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist