Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019030941 | IL |
N | 122300000X | Dentist | DD4038 | NM |
NPI | 1003187956 |
---|---|
Provider Name | Dr. Jonathan L Gifford |
First Address | Des Plaines, IL 60016-1109 |
Second Address | Mount Prospect, IL 60056-3031 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2012 |
Last Update Date | 02/03/2017 |