Provider Demographics
NPI:1962518860
Name:CORRIVEAU, JEAN
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:CORRIVEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629
Mailing Address - Country:US
Mailing Address - Phone:217-483-5019
Mailing Address - Fax:217-483-5019
Practice Address - Street 1:1209 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629
Practice Address - Country:US
Practice Address - Phone:217-483-5019
Practice Address - Fax:217-483-5019
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190138011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice