Provider Demographics
NPI:1649245150
Name:SUIT, JACK A (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:SUIT
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 1:102 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-2818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-2818
Practice Address - Country:US
Practice Address - Phone:620-431-1222
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS59381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice