Provider Demographics
NPI:1104887439
Name:JUNGBLUTH, PERRIN SAVILLE (DDS, MD)
Entity type:Individual
Prefix:
First Name:PERRIN
Middle Name:SAVILLE
Last Name:JUNGBLUTH
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N LEONARD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3166
Mailing Address - Country:US
Mailing Address - Phone:816-232-5085
Mailing Address - Fax:
Practice Address - Street 1:3109 FREDERICK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2911
Practice Address - Country:US
Practice Address - Phone:816-364-4774
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0159971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOL51D558AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER