Provider Demographics
NPI:1164836748
Name:JASEK, MARCIN (DDS)
Entity Type:Individual
Prefix:
First Name:MARCIN
Middle Name:
Last Name:JASEK
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 1:227 FOXFIRE PL
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-2993
Mailing Address - Country:US
Mailing Address - Phone:815-742-2466
Mailing Address - Fax:
Practice Address - Street 1:6417 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4421
Practice Address - Country:US
Practice Address - Phone:815-282-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist