Provider Demographics
NPI:1053881797
Name:DENZEL D. JINES II DMD PC
Entity type:Organization
Organization Name:DENZEL D. JINES II DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEYHAUPT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-647-2828
Mailing Address - Street 1:1501 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3038
Mailing Address - Country:US
Mailing Address - Phone:314-647-2828
Mailing Address - Fax:314-647-2793
Practice Address - Street 1:1501 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3038
Practice Address - Country:US
Practice Address - Phone:314-647-2828
Practice Address - Fax:314-647-2793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1841350220OtherINDIVIDAUAL NPI