Provider Demographics
NPI:1639268972
Name:JAMES B THEILEN DDS &JERRY E THEILEN DDS PC
Entity Type:Organization
Organization Name:JAMES B THEILEN DDS &JERRY E THEILEN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:THEILEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-454-1313
Mailing Address - Street 1:244 E US HIGHWAY 69
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLAYCOMO
Mailing Address - State:MO
Mailing Address - Zip Code:64119-3115
Mailing Address - Country:US
Mailing Address - Phone:816-454-1313
Mailing Address - Fax:816-454-5377
Practice Address - Street 1:244 E US HIGHWAY 69
Practice Address - Street 2:SUITE 101
Practice Address - City:CLAYCOMO
Practice Address - State:MO
Practice Address - Zip Code:64119-3115
Practice Address - Country:US
Practice Address - Phone:816-454-1313
Practice Address - Fax:816-454-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12550122300000X
MO12551122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty