Provider Demographics
NPI:1407875289
Name:CONDREY, JACK MESSENGER JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MESSENGER
Last Name:CONDREY
Suffix:JR
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 1:5306 PARKSHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-2000
Mailing Address - Country:US
Mailing Address - Phone:843-552-1600
Mailing Address - Fax:843-552-0049
Practice Address - Street 1:5306 PARKSHIRE WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-2000
Practice Address - Country:US
Practice Address - Phone:843-552-1600
Practice Address - Fax:843-552-0049
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC992785Medicaid