Provider Demographics
NPI:1265599864
Name:PLEDGER, JAMES WILLIS II (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILLIS
Last Name:PLEDGER
Suffix:II
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 1:2807 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-682-1213
Mailing Address - Fax:
Practice Address - Street 1:2807 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-682-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN83341223S0112X
KY88411223S0112X
KY847204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP900017665OtherMEDICARE PTAN
TN1518871Medicaid
KYPHYSICIAN 7100117360Medicaid
TN103I858683Medicare UPIN
KYDENTAL 7100114470Medicaid