Provider Demographics
NPI:1659376168
Name:JAYNES, PHILIP CONRAD (DDS,MS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:CONRAD
Last Name:JAYNES
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 E BROADWAY
Mailing Address - Street 2:STE 209
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8076
Mailing Address - Country:US
Mailing Address - Phone:573-443-7230
Mailing Address - Fax:573-256-8720
Practice Address - Street 1:1502 E BROADWAY
Practice Address - Street 2:STE 209
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8076
Practice Address - Country:US
Practice Address - Phone:573-443-7230
Practice Address - Fax:573-256-8720
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0119541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics