Provider Demographics
NPI:1801388327
Name:DRISSELL, JEFFREY (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:DRISSELL
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 1:10374 OLD OLIVE STREET RD APT 340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5909
Mailing Address - Country:US
Mailing Address - Phone:314-852-0713
Mailing Address - Fax:
Practice Address - Street 1:980 KEHRS MILL RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2402
Practice Address - Country:US
Practice Address - Phone:636-230-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180178271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice