Basic Information
| Provider Information | |||||||||
| NPI: | 1104010487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624461 | ||||||||
| FaxNumber: | 7195847694 | ||||||||
| Practice Location | |||||||||
| Address1: | 136 LAKE ST | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | NEWBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125505245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455651677 | ||||||||
| FaxNumber: | 8455655377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 10131-1 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 031081 | 01 | NY | NY LICENSE | OTHER |