Provider Demographics
NPI:1629140769
Name:FABER, JACK E (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:FABER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1210
Mailing Address - Country:US
Mailing Address - Phone:616-772-2868
Mailing Address - Fax:616-772-4805
Practice Address - Street 1:25 N STATE ST
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1210
Practice Address - Country:US
Practice Address - Phone:616-772-2868
Practice Address - Fax:616-772-4805
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI084661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice