Healthcare Provider Details

I. General information

NPI: 1942681994
Provider Name (Legal Business Name): J. WARREN HILDRETH, JR DDS PC OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 E MOUNT VERNON BLVD
MOUNT VERNON MO
65712-2102
US

IV. Provider business mailing address

558 E MOUNT VERNON BLVD
MOUNT VERNON MO
65712-2102
US

V. Phone/Fax

Practice location:
  • Phone: 417-466-7196
  • Fax: 417-466-2129
Mailing address:
  • Phone: 417-466-7196
  • Fax: 417-466-2129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN GEORGE
Title or Position: CEO
Credential:
Phone: 417-466-7196