Provider Demographics
NPI:1588612386
Name:THE CENTER FOR JAW AND FACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:THE CENTER FOR JAW AND FACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:IVOR
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:217-342-4444
Mailing Address - Street 1:901 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2191
Mailing Address - Country:US
Mailing Address - Phone:217-342-4444
Mailing Address - Fax:217-347-8928
Practice Address - Street 1:901 MEDICAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2191
Practice Address - Country:US
Practice Address - Phone:217-342-4444
Practice Address - Fax:217-347-8928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190193841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT87090Medicare UPIN