Provider Demographics
NPI:1508433822
Name:JAICKS, JOHN ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:JAICKS
Suffix:
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 1:590 FARRINGTON HWY UNIT 523
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 FARRINGTON HWY UNIT 523
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2034
Practice Address - Country:US
Practice Address - Phone:808-674-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-06
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026526122300000X
HIDT-3135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist