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General NPI Number Information
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NPI Number | 1003187956
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Entity Type | Individual
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Provider Name | JONATHAN L GIFFORD DDS
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Gender | Male
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Dates
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Enumeration Date | 01/24/2012
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Last Update Date | 03/02/2017
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Provider Practice Location Address
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Address Line | 435 W PROSPECT AVE
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City | MOUNT PROSPECT
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State | IL
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Zip | 60056-3031
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Country | US
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Telephone | 847-255-9690
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Fax |
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Provider Business Mailing Address
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Address Line | 783 MARK AVE
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City | DES PLAINES
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State | IL
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Zip | 60016-1109
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Country | US
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Telephone | 414-916-2863
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019030941
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD4038
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License Number State | NM
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