Provider Demographics
NPI:1568678787
Name:JACK IRVIN D.D.S., INC.
Entity Type:Organization
Organization Name:JACK IRVIN D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HARVEY
Authorized Official - Last Name:IRVIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-264-5321
Mailing Address - Street 1:220 FERNWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:WINTERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43953-9616
Mailing Address - Country:US
Mailing Address - Phone:740-264-5321
Mailing Address - Fax:
Practice Address - Street 1:220 FERNWOOD ROAD
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-9616
Practice Address - Country:US
Practice Address - Phone:740-264-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH187671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty