Provider Demographics
NPI:1427337732
Name:OUDIN, JONATHAN ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:OUDIN
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 1:1700 E BOGARD RD STE A201
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6569
Mailing Address - Country:US
Mailing Address - Phone:907-373-8455
Mailing Address - Fax:907-373-8456
Practice Address - Street 1:1700 E BOGARD RD STE A201
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6569
Practice Address - Country:US
Practice Address - Phone:907-373-8455
Practice Address - Fax:907-373-8456
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25644122300000X
AK1390122300000X
AKDEND13901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist