Provider Demographics
NPI:1811065683
Name:CHISHOLM, JON RALPH (DDS)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:RALPH
Last Name:CHISHOLM
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 1:10 S 300 W
Mailing Address - Street 2:P.O BOX 266
Mailing Address - City:SANTAQUIN
Mailing Address - State:UT
Mailing Address - Zip Code:84655-8147
Mailing Address - Country:US
Mailing Address - Phone:801-754-0678
Mailing Address - Fax:801-754-1157
Practice Address - Street 1:10 S 300 W
Practice Address - Street 2:
Practice Address - City:SANTAQUIN
Practice Address - State:UT
Practice Address - Zip Code:84655-8147
Practice Address - Country:US
Practice Address - Phone:801-754-0678
Practice Address - Fax:801-754-1157
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9734197299211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice