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General NPI Number Information
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NPI Number | 1750591590
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Entity Type | Individual
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Provider Name | GLENN JAMES JIVIDEN JR. D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4300 LINDEN AVE
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City | DAYTON
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State | OH
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Zip | 45432-3022
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Country | US
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Telephone | 937-259-0072
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Fax | 937-259-0383
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Provider Business Mailing Address
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Address Line | 4300 LINDEN AVE
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City | DAYTON
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State | OH
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Zip | 45432-3022
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Country | US
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Telephone | 937-259-0072
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Fax | 937-259-0383
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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 | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 30-01-8124
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License Number State | OH
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