Provider Demographics
NPI:1619186392
Name:LEVERETT, JACK H JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:H
Last Name:LEVERETT
Suffix:JR
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 1:1515 MILULI AVE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-5701
Mailing Address - Country:US
Mailing Address - Phone:229-246-1548
Mailing Address - Fax:
Practice Address - Street 1:1515 MILULI AVE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-5701
Practice Address - Country:US
Practice Address - Phone:229-246-1548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 110991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice