Healthcare Provider Details

I. General information

NPI: 1750591590
Provider Name (Legal Business Name): GLENN JAMES JIVIDEN JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 LINDEN AVE
DAYTON OH
45432-3022
US

IV. Provider business mailing address

4300 LINDEN AVE
DAYTON OH
45432-3022
US

V. Phone/Fax

Practice location:
  • Phone: 937-259-0072
  • Fax: 937-259-0383
Mailing address:
  • Phone: 937-259-0072
  • Fax: 937-259-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30-01-8124
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: