Provider Demographics
NPI:1649496282
Name:PIVO, JONATHAN DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:PIVO
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 1:12849 MAGNOLIA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2356
Mailing Address - Country:US
Mailing Address - Phone:818-766-3777
Mailing Address - Fax:
Practice Address - Street 1:12849 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2356
Practice Address - Country:US
Practice Address - Phone:818-766-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA536451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice