MEDICARE: DR. JERRY EDWARD THEILEN DDS

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	122300000X	Dentist	012551	MO

General Provider Information

NPI Number	:	1437342417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY EDWARD THEILEN DDS

Provider Business Mailing Address
First Line	:	244 E US 69 HWY
Second Line	:	SUITE 101
City	:	CLAYCOMO
State	:	MO
Zip	:	64119-3115
Country	:	US
Telephone Number	:	816-454-1313
Fax Number	:	816-454-5377

Provider Business Practice Location Address
First Line	:	244 E US 69 HWY
Second Line	:	SUITE 101
City	:	CLAYCOMO
State	:	MO
Zip	:	64119-3115
Country	:	US
Telephone Number	:	816-454-1313
Fax Number	:	816-454-5377

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	08/22/2007

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