Provider Demographics
NPI:1194027698
Name:ACHEATEL, JACK ROSS
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ROSS
Last Name:ACHEATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18856 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324
Mailing Address - Country:US
Mailing Address - Phone:818-885-7116
Mailing Address - Fax:
Practice Address - Street 1:18856 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-885-7116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice