Healthcare Provider Details

I. General information

NPI: 1124608419
Provider Name (Legal Business Name): DESIREE CONTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2021
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-4012
  • Fax:
Mailing address:
  • Phone: 309-624-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019036952
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5620
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: