1992048961 NPI number — JESSICA PICKEL DENTAL HYGENTIST

Table of content: JESSICA PICKEL DENTAL HYGENTIST (NPI 1992048961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992048961 NPI number — JESSICA PICKEL DENTAL HYGENTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKEL
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DENTAL HYGENTIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992048961
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW MADRID
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63869-0400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-748-2404
Provider Business Mailing Address Fax Number:
573-748-2554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6724 STATE HIGHWAY 77
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63736-8238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-545-4191
Provider Business Practice Location Address Fax Number:
573-545-4425
Provider Enumeration Date:
03/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  2006038578 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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