Provider Demographics
NPI:1922230721
Name:THOMAS, JONATHON VAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:VAN
Last Name:THOMAS
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:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-0338
Mailing Address - Country:US
Mailing Address - Phone:405-247-7676
Mailing Address - Fax:405-247-1153
Practice Address - Street 1:322 SE 11TH ST
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-4446
Practice Address - Country:US
Practice Address - Phone:405-247-7676
Practice Address - Fax:405-247-1153
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100091680AMedicaid