Provider Demographics
NPI:1659596393
Name:DIVELY, JON KARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:KARL
Last Name:DIVELY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DOCTORS LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3376
Mailing Address - Country:US
Mailing Address - Phone:309-837-3918
Mailing Address - Fax:
Practice Address - Street 1:4 DOCTORS LN
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3376
Practice Address - Country:US
Practice Address - Phone:309-837-3918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A139621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice