Provider Demographics
NPI:1861433096
Name:PUTNAM, JONATHAN LANE (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LANE
Last Name:PUTNAM
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 1:150 FAIRVIEW RD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9500
Mailing Address - Country:US
Mailing Address - Phone:704-799-3247
Mailing Address - Fax:866-623-7002
Practice Address - Street 1:150 FAIRVIEW RD
Practice Address - Street 2:SUITE 135
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9500
Practice Address - Country:US
Practice Address - Phone:704-799-3247
Practice Address - Fax:866-623-7002
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice