Healthcare Provider Details

I. General information

NPI: 1639268972
Provider Name (Legal Business Name): JAMES B THEILEN DDS &JERRY E THEILEN DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 E US HIGHWAY 69 SUITE 101
CLAYCOMO MO
64119-3115
US

IV. Provider business mailing address

244 E US HIGHWAY 69 SUITE 101
CLAYCOMO MO
64119-3115
US

V. Phone/Fax

Practice location:
  • Phone: 816-454-1313
  • Fax: 816-454-5377
Mailing address:
  • Phone: 816-454-1313
  • Fax: 816-454-5377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12550
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12551
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JAMES B THEILEN
Title or Position: DENTIST PRESIDENT
Credential: DDS
Phone: 816-454-1313