MEDICARE: SAMUEL LEE DONAVON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	01903713	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	019037193	OTHER	IL	GENERAL DENTIST

General Provider Information

NPI Number	:	1164357737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL LEE DONAVON DMD

Provider Business Mailing Address
First Line	:	21 GLEN ED PROFESSIONAL PARK
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3333
Country	:	US
Telephone Number	:	618-656-0608
Fax Number	:	618-656-0615

Provider Business Practice Location Address
First Line	:	21 GLEN ED PROFESSIONAL PARK
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3333
Country	:	US
Telephone Number	:	618-656-0608
Fax Number	:	618-656-0615

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2026
Last Update Date	:	06/16/2026

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