Provider Demographics
NPI:1871278275
Name:BUEN-GHARIB, JOHNATHON AUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHNATHON AUSTIN
Middle Name:
Last Name:BUEN-GHARIB
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 1:1925 N 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3613
Mailing Address - Country:US
Mailing Address - Phone:708-466-5130
Mailing Address - Fax:
Practice Address - Street 1:1128 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1013
Practice Address - Country:US
Practice Address - Phone:708-386-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist