Provider Demographics
NPI:1609858356
Name:BUHROW, JACK A (DDS,, MS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:BUHROW
Suffix:
Gender:M
Credentials:DDS,, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 N 12TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-521-5150
Mailing Address - Fax:
Practice Address - Street 1:1441 N 12TH ST FL 3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:602-521-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery