1194115865 NPI number — JACKSON FAMILY DENTAL GLADSTONE LLC

Table of content: (NPI 1194115865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194115865 NPI number — JACKSON FAMILY DENTAL GLADSTONE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON FAMILY DENTAL GLADSTONE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1194115865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2109 NE 72ND ST
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
GLADSTONE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64118-2304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-453-3100
Provider Business Mailing Address Fax Number:
816-453-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2109 NE 72ND ST
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
GLADSTONE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64118-2304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-453-3100
Provider Business Practice Location Address Fax Number:
816-453-3180
Provider Enumeration Date:
02/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JESSE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
816-429-5799

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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