Provider Demographics
NPI:1518187210
Name:DUCLOS, JACK B (DDS, MS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:B
Last Name:DUCLOS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 W NORTHERN LIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-3342
Mailing Address - Country:US
Mailing Address - Phone:907-272-3200
Mailing Address - Fax:
Practice Address - Street 1:1836 W NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99517-3342
Practice Address - Country:US
Practice Address - Phone:907-272-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK8711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0871Medicaid