Healthcare Provider Details

I. General information

NPI: 1881813392
Provider Name (Legal Business Name): JEREMY J YOUNGBLOOD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 N OAK TRFY SUITE 102
KANSAS CITY MO
64118-4705
US

IV. Provider business mailing address

6301 N OAK TRFY SUITE 102
KANSAS CITY MO
64118-4705
US

V. Phone/Fax

Practice location:
  • Phone: 816-453-2323
  • Fax: 816-453-3130
Mailing address:
  • Phone: 816-453-2323
  • Fax: 816-453-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number013891
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: