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General NPI Number Information
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NPI Number | 1689950503
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Entity Type | Individual
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Provider Name | JARED MICHAEL SOUTHWELL DMD
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Gender | Male
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Dates
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Enumeration Date | 10/24/2011
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Last Update Date | 08/01/2025
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Provider Practice Location Address
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Address Line | 2901 ST. JOHN'S BLVD
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City | JOPLIN
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State | MO
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Zip | 64804-1598
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Country | US
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Telephone | 417-208-0630
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Fax |
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Provider Business Mailing Address
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Address Line | 2901 SAINT JOHNS BLVD
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City | JOPLIN
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State | MO
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Zip | 64804-1598
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Country | US
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Telephone | 417-208-0630
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD3690
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2025023621
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License Number State | MO
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