Provider Demographics
NPI:1285656645
Name:JAKSIC, NICHOLAS STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:STEPHEN
Last Name:JAKSIC
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:STEPHEN
Other - Last Name:JAKSIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1360 WEST 6TH STREET
Mailing Address - Street 2:SUITE 285
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732
Mailing Address - Country:US
Mailing Address - Phone:310-832-1181
Mailing Address - Fax:310-832-3722
Practice Address - Street 1:1360 WEST 6TH STREET
Practice Address - Street 2:SUITE 285
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732
Practice Address - Country:US
Practice Address - Phone:310-832-1181
Practice Address - Fax:310-832-3722
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA380581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice