Provider Demographics
NPI:1760599732
Name:JEFFERSON CITY ORAL AND MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:JEFFERSON CITY ORAL AND MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-635-7216
Mailing Address - Street 1:1400 SOUTHWEST BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2490
Mailing Address - Country:US
Mailing Address - Phone:573-635-7216
Mailing Address - Fax:573-635-2646
Practice Address - Street 1:1400 SOUTHWEST BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2490
Practice Address - Country:US
Practice Address - Phone:573-635-7216
Practice Address - Fax:573-635-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty