Jon Karl Dively, DDS
Individual provider Active NPI General Practice Dentistry · Macomb, IL
NPI 1659596393 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1659596393
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 19A13962 (IL)
- Practice address
- 4 Doctors LN
Macomb, IL 61455-3376 - Phone
- (309) 837-3918
- NPI assigned
- Apr 16, 2007
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- HHS exclusion list flag
- The National Provider Directory flags this NPI as appearing on an HHS exclusion list.
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 19A13962 | IL | MD | General Practice Dentistry |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 19A13962 | IL | Yes |
Addresses
Primary practice location
4 Doctors LN
Macomb, IL 61455-3376
Mailing address
4 Doctors LN
Macomb, IL 61455-3376
Phone (309) 837-3918
Other providers in Macomb, IL
- Sabreen Dassa
- David R Culver OD LTD
- Denman Services, Inc
- Marilyn Kay Derry
- Rebecca E Derry
- Diana Brook Dobier
- Nicholas D Doll
- Kaylen Paige Dorich
- Dr Eric Botts & Associates LLC
- Kristen Jean Draughan
All providers in Macomb, IL · General Practice Dentistry in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.