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General NPI Number Information
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NPI Number | 1174662621
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Entity Type | Individual
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Provider Name | JON RAMON GARDNER DMD
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Gender | Male
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Dates
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Enumeration Date | 02/05/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 12078 IL RTE 185 GRAHAM CORRECTIONAL CENTER
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City | HILLSBORO
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State | IL
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Zip | 62049
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Country | US
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Telephone | 217-532-6961
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Fax | 217-532-3964
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Provider Business Mailing Address
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Address Line | 5 SOMERSET PL
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City | COLLINSVILLE
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State | IL
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Zip | 62234-8000
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Country | US
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Telephone | 618-346-6698
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Fax | 618-346-6801
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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 | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | 19023167
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License Number State | IL
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