Provider Demographics
NPI:1750591590
Name:JIVIDEN, GLENN JAMES JR (DDS)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JAMES
Last Name:JIVIDEN
Suffix:JR
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 1:4300 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-3022
Mailing Address - Country:US
Mailing Address - Phone:937-259-0072
Mailing Address - Fax:937-259-0383
Practice Address - Street 1:4300 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3022
Practice Address - Country:US
Practice Address - Phone:937-259-0072
Practice Address - Fax:937-259-0383
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-81241223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30-01-8124OtherSTATE DENTAL LICENSE