Provider Demographics
NPI:1225258726
Name:RICHARD, JACK MELVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MELVIN
Last Name:RICHARD
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:PO BOX 157
Mailing Address - Street 2:15 SW 20TH AVENUE
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-0157
Mailing Address - Country:US
Mailing Address - Phone:360-687-5665
Mailing Address - Fax:360-687-5053
Practice Address - Street 1:15 SW 20TH AVENUE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604
Practice Address - Country:US
Practice Address - Phone:360-687-5665
Practice Address - Fax:360-687-5053
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7107122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist