Provider Demographics
NPI:1518306778
Name:MACK, JEFFREY R (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:MACK
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 1:1085 N BLACK HORSE PIKE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-2800
Mailing Address - Country:US
Mailing Address - Phone:856-728-3519
Mailing Address - Fax:856-728-2824
Practice Address - Street 1:1085 N BLACK HORSE PIKE
Practice Address - Street 2:SUITE 3
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-2800
Practice Address - Country:US
Practice Address - Phone:856-728-3519
Practice Address - Fax:856-728-2824
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11862122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist