Provider Demographics
NPI:1346306206
Name:BEHN, JACK WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WILLIAM
Last Name:BEHN
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 1:8200 W SUNRISE BLVD
Mailing Address - Street 2:A 1
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322
Mailing Address - Country:US
Mailing Address - Phone:954-318-1966
Mailing Address - Fax:954-473-2742
Practice Address - Street 1:8200 W SUNRISE BLVD
Practice Address - Street 2:A 1
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322
Practice Address - Country:US
Practice Address - Phone:954-318-1966
Practice Address - Fax:954-473-2742
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL77771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL86854OtherBLUE CROSS BLUE SHIELD
035149OtherTRICARE