Basic Information
| Provider Information | |||||||||
| NPI: | 1861740722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CZEREPAK | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | LESLIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 226 BAINBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308097302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034912050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2716 RIELLY ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106432196 | ||||||||
| FaxNumber: | 9103967017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2012 | ||||||||
| LastUpdateDate: | 08/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | DN1856104 | MA | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 122300000X | DN1856104 | MA | Y | Dental Providers | Dentist | 1223G0001X | DN1856104 | MA | N | Dental Providers | Dentist | General Practice |
No ID Information.