Provider Demographics
NPI:1881813392
Name:YOUNGBLOOD, JEREMY J (DDS)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:YOUNGBLOOD
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 1:6301 N OAK TRFY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-4705
Mailing Address - Country:US
Mailing Address - Phone:816-453-2323
Mailing Address - Fax:816-453-3130
Practice Address - Street 1:6301 N OAK TRFY
Practice Address - Street 2:SUITE 102
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4705
Practice Address - Country:US
Practice Address - Phone:816-453-2323
Practice Address - Fax:816-453-3130
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0138911223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics