Provider Demographics
NPI:1093954323
Name:MORRISON, JACK WALLACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WALLACE
Last Name:MORRISON
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 1:10105 WOODSONG WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-4213
Mailing Address - Country:US
Mailing Address - Phone:813-935-0879
Mailing Address - Fax:
Practice Address - Street 1:18850 DALE MABRY HWY N
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4978
Practice Address - Country:US
Practice Address - Phone:813-949-6969
Practice Address - Fax:813-949-3918
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN004665122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist