Glenn James Jividen Jr., D.D.S.

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

30-01-8124 Issued in OH

Practice address

4300 Linden Ave
Dayton, OH 45432-3022

Phone

(937) 259-0072

Fax

(937) 259-0383

NPI assigned

May 23, 2007

Sex

Male

Sole proprietor

No

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

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

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

{
    "created_epoch": "1179878400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1750591590",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4300 LINDEN AVE",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454323022",
            "telephone_number": "937-259-0072",
            "fax_number": "937-259-0383"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4300 LINDEN AVE",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454323022",
            "telephone_number": "937-259-0072",
            "fax_number": "937-259-0383"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JIVIDEN",
        "first_name": "GLENN",
        "middle_name": "JAMES",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-23",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "OH",
            "license": "30-01-8124",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE DENTAL LICENSE",
            "identifier": "30-01-8124",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Olivia Jimenez Benner
• Katie Jiner
• Sanjay Krishna Ashoka Jinka, MD
• Rajkamal Jit, MD
• Brent Hamilton Jividen, PT
• Joshua Alexander Jividen, DPT
• Jo Yvette Pelfrey, M.D.
• Joana'S
• Karen A Jobalia, MD
• Joe Haney'S Transportation Services,LTD

• Periodontics in Dayton, OH
• Providers in Dayton, OH by specialty
• Periodontics in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.