Active NPI
Jacklyn Aliza Pivovarov, DDS
- General Practice Dentistry
- Princess Anne, MD
National Provider Identifier
1790346229
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- LL857
- Practice address
- 12165 Elm St
Princess Anne, MD 21853-1358 - Phone
- (410) 651-5151
- Fax
- (410) 651-4256
- NPI assigned
- Jun 25, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | LL857 | MD | Primary |
Addresses
Primary practice location
12165 Elm St
Princess Anne, MD 21853-1358
Mailing address
PO Box 1978
Salisbury, MD 21802-1978
Phone (410) 749-1015
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 119591300 | Medicaid | MD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LL857 | MD | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1561420800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1562630400000",
"number": "1790346229",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1978",
"city": "SALISBURY",
"state": "MD",
"postal_code": "218021978",
"telephone_number": "410-749-1015",
"fax_number": "410-749-0654"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12165 ELM ST",
"city": "PRINCESS ANNE",
"state": "MD",
"postal_code": "218531358",
"telephone_number": "410-651-5151",
"fax_number": "410-651-4256"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PIVOVAROV",
"first_name": "JACKLYN",
"middle_name": "ALIZA",
"name_prefix": "Ms.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-06-25",
"last_updated": "2019-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MD",
"license": "LL857",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "119591300",
"state": "MD"
}
],
"endpoints": [],
"other_names": []
}Other providers in Princess Anne, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.