Provider Demographics
NPI:1306860556
Name:HENRY, JACK ALBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALBERT
Last Name:HENRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18709 MIRKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-7507
Mailing Address - Country:US
Mailing Address - Phone:503-638-0385
Mailing Address - Fax:
Practice Address - Street 1:3993 LAKE GROVE AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4493
Practice Address - Country:US
Practice Address - Phone:503-636-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 55001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice