Provider Demographics
NPI:1588063630
Name:MEALY, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MEALY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MEALY LN
Mailing Address - Street 2:
Mailing Address - City:TIONESTA
Mailing Address - State:PA
Mailing Address - Zip Code:16353-2420
Mailing Address - Country:US
Mailing Address - Phone:804-212-5777
Mailing Address - Fax:
Practice Address - Street 1:217 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:OIL CITY
Practice Address - State:PA
Practice Address - Zip Code:16301-1443
Practice Address - Country:US
Practice Address - Phone:814-670-0374
Practice Address - Fax:814-670-0376
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist