Healthcare Provider Details

I. General information

NPI: 1619329471
Provider Name (Legal Business Name): JON OWEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N MAIN ST
SMITHTON IL
62285-1518
US

IV. Provider business mailing address

504 N MAIN ST
SMITHTON IL
62285-1518
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-9012
  • Fax: 618-233-2399
Mailing address:
  • Phone: 618-233-9012
  • Fax: 618-233-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019030660
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.030660
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: