Provider Demographics
NPI:1952403040
Name:J. WARREN HILDRETH, JR DDS PC OF MISSOURI
Entity type:Organization
Organization Name:J. WARREN HILDRETH, JR DDS PC OF MISSOURI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:HILDRETH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-466-7184
Mailing Address - Street 1:1050 W HAYWARD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-6329
Mailing Address - Country:US
Mailing Address - Phone:417-466-7184
Mailing Address - Fax:417-466-4081
Practice Address - Street 1:1050 W HAYWARD DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-6329
Practice Address - Country:US
Practice Address - Phone:417-466-7184
Practice Address - Fax:417-466-4081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0112261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty