MEDICARE: DENZEL D. JINES II DMD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1841350220	OTHER	MO	INDIVIDAUAL NPI

General Provider Information

NPI Number	:	1053881797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENZEL D. JINES II DMD PC

Provider Business Mailing Address
First Line	:	1501 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-3038
Country	:	US
Telephone Number	:	314-647-2828
Fax Number	:	314-647-2793

Provider Business Practice Location Address
First Line	:	1501 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-3038
Country	:	US
Telephone Number	:	314-647-2828
Fax Number	:	314-647-2793

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	KATHERINE E WEYHAUPT
Credential	:
Telephone Number	:	314-647-2828

Provider Enumeration Date	:	11/26/2018
Last Update Date	:	11/26/2018

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