Provider Demographics
NPI:1033235023
Name:GEORGE, JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31441 SANTA MARGARITA PKWY
Mailing Address - Street 2:SUITE G
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1836
Mailing Address - Country:US
Mailing Address - Phone:949-589-7820
Mailing Address - Fax:949-589-2301
Practice Address - Street 1:31441 SANTA MARGARITA PKWY
Practice Address - Street 2:SUITE G
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-1836
Practice Address - Country:US
Practice Address - Phone:949-589-7820
Practice Address - Fax:949-589-2301
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2013-09-11
Deactivation Date:2009-03-11
Deactivation Code:
Reactivation Date:2013-09-11
Provider Licenses
StateLicense IDTaxonomies
CA198851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics