Provider Demographics
NPI:1003365404
Name:CESSNA, JACK ALLEN (RDH, BS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALLEN
Last Name:CESSNA
Suffix:
Gender:M
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-350-4606
Mailing Address - Fax:970-350-4645
Practice Address - Street 1:1006 A ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-2021
Practice Address - Country:US
Practice Address - Phone:970-352-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002024533124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist