Provider Demographics
NPI:1861795312
Name:JUMP DENTAL, LLC
Entity type:Organization
Organization Name:JUMP DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:JUMP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-326-2244
Mailing Address - Street 1:1300 N OAKLAND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3008
Mailing Address - Country:US
Mailing Address - Phone:417-326-2244
Mailing Address - Fax:417-326-8013
Practice Address - Street 1:1300 N OAKLAND AVE STE C
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3008
Practice Address - Country:US
Practice Address - Phone:417-326-2244
Practice Address - Fax:417-326-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1575281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty