Provider Demographics
NPI:1558457903
Name:GRIFFIN, JACK DEAN JR (DMD PC FAGD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DEAN
Last Name:GRIFFIN
Suffix:JR
Gender:M
Credentials:DMD PC FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HILLTOP VILLAGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025
Mailing Address - Country:US
Mailing Address - Phone:636-938-6241
Mailing Address - Fax:638-938-7941
Practice Address - Street 1:18 HILLTOP VILLAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025
Practice Address - Country:US
Practice Address - Phone:636-938-6241
Practice Address - Fax:638-938-7941
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist