Provider Demographics
NPI:1093367591
Name:BLEYTHING, JILL (DMD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BLEYTHING
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-0761
Mailing Address - Country:US
Mailing Address - Phone:573-438-9355
Mailing Address - Fax:573-438-7892
Practice Address - Street 1:1 SOUTHTOWNE DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:573-438-7892
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019022666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist