Provider Demographics
NPI:1184831109
Name:DORKHOM, JACK MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:DORKHOM
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 1:69A MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-1321
Mailing Address - Country:US
Mailing Address - Phone:585-586-2580
Mailing Address - Fax:585-586-4924
Practice Address - Street 1:101 SULLY'S TRL
Practice Address - Street 2:BUILDING 10
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534
Practice Address - Country:US
Practice Address - Phone:585-586-8895
Practice Address - Fax:585-485-0817
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist