Provider Demographics
NPI:1073629390
Name:KOUMJIAN, JACK H (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:H
Last Name:KOUMJIAN
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 1:770 WELCH RD
Mailing Address - Street 2:STE 280
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1513
Mailing Address - Country:US
Mailing Address - Phone:650-347-3426
Mailing Address - Fax:650-324-0103
Practice Address - Street 1:770 WELCH RD
Practice Address - Street 2:STE 280
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1513
Practice Address - Country:US
Practice Address - Phone:650-347-3426
Practice Address - Fax:650-324-0103
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3273011223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1073629390OtherDENTICAL
CADS0327301Medicare PIN