Provider Demographics
NPI:1275531048
Name:TROOP, JACK MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:TROOP
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 1:15430 E ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80016-3005
Mailing Address - Country:US
Mailing Address - Phone:303-699-4822
Mailing Address - Fax:
Practice Address - Street 1:15430 E ORCHARD RD
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80016-3005
Practice Address - Country:US
Practice Address - Phone:303-699-4822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6382410001Medicare NSC