Healthcare Provider Details

I. General information

NPI: 1689338626
Provider Name (Legal Business Name): JENNIFER OWENS-SMITH RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 N HIGHWAY 5
MANSFIELD MO
65704-7301
US

IV. Provider business mailing address

PO BOX 1359
AVA MO
65608-1359
US

V. Phone/Fax

Practice location:
  • Phone: 417-924-8809
  • Fax:
Mailing address:
  • Phone: 417-683-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2004013860
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: