Provider Demographics
NPI:1376720581
Name:GRIECHEN, JASMINE WYATT (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JASMINE
Middle Name:WYATT
Last Name:GRIECHEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 SW MISTY GLN
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-2500
Mailing Address - Country:US
Mailing Address - Phone:816-322-7600
Mailing Address - Fax:816-322-7606
Practice Address - Street 1:802 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2544
Practice Address - Country:US
Practice Address - Phone:816-322-7600
Practice Address - Fax:816-322-7606
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH22749124Q00000X
MO2009024711124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477563518Medicaid
CAFHC70081FMedicaid
CA94-2492609OtherTAX ID NUMBER