Provider Demographics
NPI:1538315130
Name:BROWN, JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BROWN
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 1:2969 HEWLETT AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-5312
Mailing Address - Country:US
Mailing Address - Phone:516-643-0424
Mailing Address - Fax:
Practice Address - Street 1:48 E KINGSBRIDGE RD FRNT 1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-7514
Practice Address - Country:US
Practice Address - Phone:718-933-9603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054002122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist