Healthcare Provider Details

I. General information

NPI: 1659376168
Provider Name (Legal Business Name): PHILIP CONRAD JAYNES DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 E BROADWAY STE 209
COLUMBIA MO
65201-8076
US

IV. Provider business mailing address

1502 E BROADWAY STE 209
COLUMBIA MO
65201-8076
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-7230
  • Fax: 573-256-8720
Mailing address:
  • Phone: 573-443-7230
  • Fax: 573-256-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number011954
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: