Provider Demographics
NPI:1053485433
Name:BALENSEIFEN, JACK WILLIAM (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WILLIAM
Last Name:BALENSEIFEN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
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Mailing Address - Street 1:7505 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-4941
Mailing Address - Country:US
Mailing Address - Phone:405-789-6772
Mailing Address - Fax:405-789-6787
Practice Address - Street 1:7505 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-4941
Practice Address - Country:US
Practice Address - Phone:405-789-6772
Practice Address - Fax:405-789-6787
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics