Provider Demographics
NPI:1306343306
Name:LUKE, JONATHAN THACHARA (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:THACHARA
Last Name:LUKE
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:PO BOX 477, 26220 POINT LOOKOUT ROAD
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2158
Mailing Address - Country:US
Mailing Address - Phone:301-475-8100
Mailing Address - Fax:
Practice Address - Street 1:26220 POINT LOOKOUT RD
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-3748
Practice Address - Country:US
Practice Address - Phone:301-475-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0425951223S0112X
MD165801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery