Provider Demographics
NPI:1265442107
Name:STANDLEE, JACKY CLAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACKY
Middle Name:CLAY
Last Name:STANDLEE
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 1:5405 WARDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-8744
Mailing Address - Country:US
Mailing Address - Phone:573-634-7313
Mailing Address - Fax:
Practice Address - Street 1:WESTSIDE DENTAL 994 DIAMOND RIDGE
Practice Address - Street 2:STE 202
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-893-4402
Practice Address - Fax:573-632-4398
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014960122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist