Provider Demographics
NPI:1316330210
Name:JONATHAN R ABRAHAM, DDS
Entity type:Organization
Organization Name:JONATHAN R ABRAHAM, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-925-0322
Mailing Address - Street 1:3814 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1528
Mailing Address - Country:US
Mailing Address - Phone:304-925-0322
Mailing Address - Fax:304-925-2337
Practice Address - Street 1:3814 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1528
Practice Address - Country:US
Practice Address - Phone:304-925-0322
Practice Address - Fax:304-925-2337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty