Provider Demographics
NPI:1568891976
Name:BRACALE, JACK (DMD,)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BRACALE
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 1:404 N LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:ROYERSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19468-1511
Mailing Address - Country:US
Mailing Address - Phone:610-948-5552
Mailing Address - Fax:
Practice Address - Street 1:404 N LEWIS RD
Practice Address - Street 2:
Practice Address - City:ROYERSFORD
Practice Address - State:PA
Practice Address - Zip Code:19468-1511
Practice Address - Country:US
Practice Address - Phone:610-948-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-026211-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist