Provider Demographics
NPI:1356886469
Name:YU, JONATHAN S (DMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:S
Last Name:YU
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 1:111 LIBERTY PKWY
Mailing Address - Street 2:APT C9
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-4871
Mailing Address - Country:US
Mailing Address - Phone:703-350-2521
Mailing Address - Fax:573-596-0410
Practice Address - Street 1:618TH DENTAL COMPANY USAG HUMPHREYS
Practice Address - Street 2:CARIUS DENTAL CLINIC UNIT 15652
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271
Practice Address - Country:US
Practice Address - Phone:315-737-9186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415390122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist