Healthcare Provider Details

I. General information

NPI: 1013399351
Provider Name (Legal Business Name): JASON KINGSOLVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 WESTWOOD DR
SEDALIA MO
65301-2102
US

IV. Provider business mailing address

305 W MAIN ST
SEDALIA MO
65301-3821
US

V. Phone/Fax

Practice location:
  • Phone: 660-826-4774
  • Fax: 660-826-1300
Mailing address:
  • Phone: 660-310-0909
  • Fax: 888-979-8868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2015016756
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: