Samuel Lee Donavon, DMD

Primary specialty

DentistTaxonomy code 122300000X

License

01903713 Issued in IL

Practice address

21 Glen Ed Professional Park
Glen Carbon, IL 62034-3333

Phone

(618) 656-0608

Fax

(618) 656-0615

NPI assigned

Jun 16, 2026

Last updated

Jun 16, 2026By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Sones Family Dental, LLC

  • Dentist
  • Glen Carbon, IL
  • NPI 1700206406
  NPD (past)
• Troy Dental Associates LLC

  • Dentist
  • Troy, IL
  • NPI 1801758446
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1781568000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1781568000000",
    "number": "1164357737",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21 GLEN ED PROFESSIONAL PARK",
            "city": "GLEN CARBON",
            "state": "IL",
            "postal_code": "620343333",
            "telephone_number": "618-656-0608",
            "fax_number": "618-656-0615"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21 GLEN ED PROFESSIONAL PARK",
            "city": "GLEN CARBON",
            "state": "IL",
            "postal_code": "620343333",
            "telephone_number": "618-656-0608",
            "fax_number": "618-656-0615"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DONAVON",
        "first_name": "SAMUEL",
        "middle_name": "LEE",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2026-06-16",
        "last_updated": "2026-06-16",
        "certification_date": "2026-06-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "IL",
            "license": "01903713",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GENERAL DENTIST",
            "identifier": "019037193",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brooke Brianne Deters, DMD
• Randi Deyong
• Lizbeth Hoepli Didriksen, M.D.
• Ryan Diederich, MD
• Dennis Dietzen
• Dover Hospice Il STL Metro, LLC
• Sara Downey, MSW, LCSW
• Dr. Mary Mioux-Berry, LLC
• Hannah Elizabeth Dudiak
• Kristi Duelm, LCPC

• Dentist in Glen Carbon, IL
• Providers in Glen Carbon, IL by specialty
• Dentist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.