Provider Demographics
NPI:1255468005
Name:DEGRADO, JACK D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:DEGRADO
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 1:47 OAK ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5316
Mailing Address - Country:US
Mailing Address - Phone:203-325-4700
Mailing Address - Fax:
Practice Address - Street 1:47 OAK ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5316
Practice Address - Country:US
Practice Address - Phone:203-325-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0085071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics