Provider Demographics
NPI:1538203013
Name:SODONIS, JEROME LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:LOUIS
Last Name:SODONIS
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 1:2463 WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2709
Mailing Address - Country:US
Mailing Address - Phone:248-649-5635
Mailing Address - Fax:
Practice Address - Street 1:18514 MACK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3256
Practice Address - Country:US
Practice Address - Phone:313-885-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI109521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice