Provider Demographics
NPI:1487666467
Name:WILLOUGHBY, JACK EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:EDWARD
Last Name:WILLOUGHBY
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 1:1222 S KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5855
Mailing Address - Country:US
Mailing Address - Phone:405-341-8518
Mailing Address - Fax:405-715-2494
Practice Address - Street 1:1222 S KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5855
Practice Address - Country:US
Practice Address - Phone:405-341-8518
Practice Address - Fax:405-715-2494
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK41501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice