Healthcare Provider Details

I. General information

NPI: 1992136923
Provider Name (Legal Business Name): JACKSON DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E JACKSON BLVD
JACKSON MO
63755-2957
US

IV. Provider business mailing address

3100 E JACKSON BLVD
JACKSON MO
63755-2957
US

V. Phone/Fax

Practice location:
  • Phone: 573-243-5200
  • Fax: 573-243-7571
Mailing address:
  • Phone: 573-243-5200
  • Fax: 573-243-7571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2011014478
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. CODY BELL
Title or Position: OWNER
Credential: DDS
Phone: 573-243-5200