Provider Demographics
NPI:1376752063
Name:SHAPIRO, JACK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:SHAPIRO
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 1:1000 RIVER ROCK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-2093
Mailing Address - Country:US
Mailing Address - Phone:916-988-0655
Mailing Address - Fax:916-988-3941
Practice Address - Street 1:1000 RIVER ROCK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-2093
Practice Address - Country:US
Practice Address - Phone:916-988-0655
Practice Address - Fax:916-988-3941
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADP0321781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice