Basic Information
| Provider Information | |||||||||
| NPI: | 1710581277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JONATHAN MIODOWNIK DMD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24764 SOUTHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480752715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485572618 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24764 SOUTHFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480752715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485572618 | ||||||||
| FaxNumber: | 2485573211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2020 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | MIODOWNIK | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 2485572618 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.