Provider Demographics
NPI:1861981979
Name:SHADBURNE, JONATHAN DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:SHADBURNE
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 1:124 GOODVIEW WAY STE B
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-4927
Mailing Address - Country:US
Mailing Address - Phone:615-575-3344
Mailing Address - Fax:
Practice Address - Street 1:124 GOODVIEW WAY STE B
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-4927
Practice Address - Country:US
Practice Address - Phone:615-575-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2023-11-15
Deactivation Date:2023-10-04
Deactivation Code:
Reactivation Date:2023-10-31
Provider Licenses
StateLicense IDTaxonomies
OH30.0256581223G0001X
390200000X
TN112821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program