Provider Demographics
NPI:1629743844
Name:SNOW, JACK (DMD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SNOW
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 1:8564 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-9437
Mailing Address - Country:US
Mailing Address - Phone:417-988-8712
Mailing Address - Fax:
Practice Address - Street 1:3109 EDGAR BROWN DR STE H
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-5381
Practice Address - Country:US
Practice Address - Phone:409-254-4759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0111121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice