Provider Demographics
NPI:1922281971
Name:HAMBLIN, JERALD
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:
Last Name:HAMBLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 N OAK TRFY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-4705
Mailing Address - Country:US
Mailing Address - Phone:816-452-2420
Mailing Address - Fax:
Practice Address - Street 1:6301 N OAK TRFY
Practice Address - Street 2:SUITE 202
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-4705
Practice Address - Country:US
Practice Address - Phone:816-452-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO011945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD09692040OtherBLUE CROSS