Provider Demographics
NPI:1114931359
Name:LEBSACK, JON PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:PATRICK
Last Name:LEBSACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 E 5TH ST
Mailing Address - Street 2:STE. 320
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3135
Mailing Address - Country:US
Mailing Address - Phone:636-239-7150
Mailing Address - Fax:
Practice Address - Street 1:851 E 5TH ST
Practice Address - Street 2:STE. 320
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3135
Practice Address - Country:US
Practice Address - Phone:636-239-7150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0147931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU20320Medicare UPIN