Provider Demographics
NPI:1902213465
Name:DAMES, JACALYN RENEE
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:RENEE
Last Name:DAMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4092 CREST DR
Mailing Address - Street 2:
Mailing Address - City:HOUSE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63051-1570
Mailing Address - Country:US
Mailing Address - Phone:636-575-8436
Mailing Address - Fax:
Practice Address - Street 1:4092 CREST DR
Practice Address - Street 2:
Practice Address - City:HOUSE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63051-1570
Practice Address - Country:US
Practice Address - Phone:636-575-8436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOX183076005122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO37424356Medicaid