Provider Demographics
NPI:1295846947
Name:OKERSTROM, JACK G (DDS, PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:OKERSTROM
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11940 QUIVIRA RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213
Mailing Address - Country:US
Mailing Address - Phone:913-469-9191
Mailing Address - Fax:913-451-2251
Practice Address - Street 1:4026 W. 83RD ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208
Practice Address - Country:US
Practice Address - Phone:913-469-9191
Practice Address - Fax:913-451-2251
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS520001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS284782Medicaid