Provider Demographics
NPI:1366435331
Name:WOODRUFF, JON MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:MICHAEL
Last Name:WOODRUFF
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 1:861 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-2401
Mailing Address - Country:US
Mailing Address - Phone:215-302-3156
Mailing Address - Fax:215-329-2369
Practice Address - Street 1:861 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-2401
Practice Address - Country:US
Practice Address - Phone:215-302-3156
Practice Address - Fax:215-329-2369
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6814122300000X
PADS044372122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100225410-BMedicaid
KS017363OtherBLUE CROSS BLUE SHIELD
PA1042785600001Medicaid
000781486OtherUNITED CONCORDIA OF KS