Healthcare Provider Details

I. General information

NPI: 1174662621
Provider Name (Legal Business Name): JON RAMON GARDNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12078 IL RTE 185 GRAHAM CORRECTIONAL CENTER
HILLSBORO IL
62049
US

IV. Provider business mailing address

5 SOMERSET PL
COLLINSVILLE IL
62234-8000
US

V. Phone/Fax

Practice location:
  • Phone: 217-532-6961
  • Fax: 217-532-3964
Mailing address:
  • Phone: 618-346-6698
  • Fax: 618-346-6801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number19023167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: