Provider Demographics
NPI:1154627230
Name:JACK T WINCHESTER DMD
Entity Type:Organization
Organization Name:JACK T WINCHESTER DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:WINCHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:252-247-3510
Mailing Address - Street 1:3705 SYMI CIR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4314
Mailing Address - Country:US
Mailing Address - Phone:252-247-3510
Mailing Address - Fax:252-247-6197
Practice Address - Street 1:3705 SYMI CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4314
Practice Address - Country:US
Practice Address - Phone:252-247-3510
Practice Address - Fax:252-247-6197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5372122300000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2417497OtherMEDICARE