Provider Demographics
NPI:1639701865
Name:KEMPER, JACK DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DAVID
Last Name:KEMPER
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 1:154 HAVEN AVE APT 1210
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1180
Mailing Address - Country:US
Mailing Address - Phone:616-644-1743
Mailing Address - Fax:
Practice Address - Street 1:60 WATERBURY RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1250
Practice Address - Country:US
Practice Address - Phone:203-527-3855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist