Provider Demographics
NPI:1366476947
Name:BAILEY, JONATHAN S (DMD, MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:S
Last Name:BAILEY
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:ORAL AND MAXILLOFACIAL SURGERY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3280
Practice Address - Fax:217-383-7071
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104913204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL91090Medicare PIN
IL6447860011Medicare NSC
IL0533210001Medicare NSC
H58213Medicare UPIN
ILIL3270069Medicare PIN
ILH58213Medicare UPIN