Healthcare Provider Details

I. General information

NPI: 1164357737
Provider Name (Legal Business Name): SAMUEL LEE DONAVON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GLEN ED PROFESSIONAL PARK
GLEN CARBON IL
62034-3333
US

IV. Provider business mailing address

21 GLEN ED PROFESSIONAL PARK
GLEN CARBON IL
62034-3333
US

V. Phone/Fax

Practice location:
  • Phone: 618-656-0608
  • Fax: 618-656-0615
Mailing address:
  • Phone: 618-656-0608
  • Fax: 618-656-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number01903713
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: