Provider Demographics
NPI:1780916981
Name:MILES, JONATHAN ROSS (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROSS
Last Name:MILES
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 1:35 MARIA DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-3548
Mailing Address - Country:US
Mailing Address - Phone:707-763-3203
Mailing Address - Fax:
Practice Address - Street 1:35 MARIA DR
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-3548
Practice Address - Country:US
Practice Address - Phone:707-763-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA244871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice