Provider Demographics
NPI:1235242652
Name:DAVIS, JACK JUSTIN (DDS)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:JUSTIN
Last Name:DAVIS
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 1:543 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-3553
Mailing Address - Country:US
Mailing Address - Phone:970-625-1391
Mailing Address - Fax:970-625-9372
Practice Address - Street 1:543 WEST AVE
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-3553
Practice Address - Country:US
Practice Address - Phone:970-625-1391
Practice Address - Fax:970-625-9372
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1049541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice