Provider Demographics
NPI:1487700993
Name:STAHL, JONATHAN MILES (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MILES
Last Name:STAHL
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 1:4179 3RD AVE
Mailing Address - Street 2:#216
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1400
Mailing Address - Country:US
Mailing Address - Phone:317-260-1332
Mailing Address - Fax:
Practice Address - Street 1:2310 CRAVEN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5596
Practice Address - Country:US
Practice Address - Phone:619-556-9942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190239251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice