Provider Demographics
NPI:1356474191
Name:EHLEN, JACK EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:EHLEN
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 1:11208 B 94TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3663
Mailing Address - Country:US
Mailing Address - Phone:253-848-4597
Mailing Address - Fax:253-841-7677
Practice Address - Street 1:11208 B 94TH AVE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3663
Practice Address - Country:US
Practice Address - Phone:253-848-4597
Practice Address - Fax:253-841-7677
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist