Provider Demographics
NPI:1144297821
Name:JUNKIN, JONATHAN BRUCE (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRUCE
Last Name:JUNKIN
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 1:540 E STATE HIGHWAY 239
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-8808
Mailing Address - Country:US
Mailing Address - Phone:910-750-2002
Mailing Address - Fax:
Practice Address - Street 1:95 US HIGHWAY 51 BYP W
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1935
Practice Address - Country:US
Practice Address - Phone:731-286-1271
Practice Address - Fax:731-286-0019
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR29871223G0001X, 1223P0221X
TN93181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN62-1399728OtherTAX ID