Provider Demographics
NPI:1578862777
Name:BULLARD, JONATHAN L (DMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:BULLARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 WASHINGTON RD.
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2848
Mailing Address - Country:US
Mailing Address - Phone:706-863-5337
Mailing Address - Fax:706-855-8249
Practice Address - Street 1:3702 WASHINGTON RD.
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-2848
Practice Address - Country:US
Practice Address - Phone:706-863-5337
Practice Address - Fax:706-855-8249
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69641223G0001X
GADN0141011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice