Provider Demographics
NPI:1174662621
Name:GARDNER, JON RAMON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:RAMON
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SOMERSET PL
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-8000
Mailing Address - Country:US
Mailing Address - Phone:618-346-6698
Mailing Address - Fax:618-346-6801
Practice Address - Street 1:12078 IL RTE 185
Practice Address - Street 2:GRAHAM CORRECTIONAL CENTER
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049
Practice Address - Country:US
Practice Address - Phone:217-532-6961
Practice Address - Fax:217-532-3964
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190231671223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health