Provider Demographics
NPI:1104010487
Name:WEISS, JONATHAN M (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:WEISS
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 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-562-4461
Mailing Address - Fax:719-584-7694
Practice Address - Street 1:136 LAKE ST
Practice Address - Street 2:SUITE 11
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5245
Practice Address - Country:US
Practice Address - Phone:845-565-1677
Practice Address - Fax:845-565-5377
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10131-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031081OtherNY LICENSE