Provider Demographics
NPI:1467674481
Name:WRIGHT, JACK G (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:WRIGHT
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 1:453 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5703
Mailing Address - Country:US
Mailing Address - Phone:480-835-0567
Mailing Address - Fax:480-733-2839
Practice Address - Street 1:453 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5703
Practice Address - Country:US
Practice Address - Phone:480-835-0567
Practice Address - Fax:480-733-2839
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD66131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics