Provider Demographics
NPI:1386814424
Name:MA, JACK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:T
Last Name:MA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9093 LAS TUNAS DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-1901
Mailing Address - Country:US
Mailing Address - Phone:626-286-1568
Mailing Address - Fax:626-286-9738
Practice Address - Street 1:9093 LAS TUNAS DR.
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-1901
Practice Address - Country:US
Practice Address - Phone:626-286-1568
Practice Address - Fax:626-286-9738
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA40666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist