Provider Demographics
NPI:1235134511
Name:JONOV, CRAIG RONALD (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:RONALD
Last Name:JONOV
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:STE 1454
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1749
Mailing Address - Country:US
Mailing Address - Phone:206-624-0852
Mailing Address - Fax:206-622-2084
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:STE 1454
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1749
Practice Address - Country:US
Practice Address - Phone:206-624-0852
Practice Address - Fax:206-622-2084
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-07-14
Provider Licenses
StateLicense IDTaxonomies
WA92461223P0106X
WA43154174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA59246OtherWASH DENTAL SERVICE
WA5041496Medicaid
WA1386802OtherUNITED CONCORDIA
WA7092322OtherAETNA
WA1605JOOtherREGENCE
WA164759OtherDEPT OF LABOR & INDUSTRIE
WAAB37279Medicare ID - Type UnspecifiedMAXILLOFACIAL SURGERY
WA5041496Medicaid