Provider Demographics
NPI:1629237763
Name:MCCALL, JACK THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:THOMAS
Last Name:MCCALL
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 1:812 S. 24TH ST.
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-1322
Mailing Address - Country:US
Mailing Address - Phone:660-425-3331
Mailing Address - Fax:
Practice Address - Street 1:812 S. 24TH ST.
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-1322
Practice Address - Country:US
Practice Address - Phone:660-425-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080141501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice