Provider Demographics
NPI:1063688091
Name:GAW, JACK L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:GAW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2313
Mailing Address - Country:US
Mailing Address - Phone:615-321-0700
Mailing Address - Fax:
Practice Address - Street 1:1926 HAYES ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2313
Practice Address - Country:US
Practice Address - Phone:615-321-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN4828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist