Provider Demographics
NPI:1689622359
Name:JACKANICH, PAUL JOSEPH JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOSEPH
Last Name:JACKANICH
Suffix:JR
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 1:841 SOUTHWESTERN RUN
Mailing Address - Street 2:STE 1
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-3688
Mailing Address - Country:US
Mailing Address - Phone:330-629-2270
Mailing Address - Fax:330-629-2271
Practice Address - Street 1:841 SOUTHWESTERN RUN
Practice Address - Street 2:STE 1
Practice Address - City:POLANO
Practice Address - State:OH
Practice Address - Zip Code:44514
Practice Address - Country:US
Practice Address - Phone:330-629-2270
Practice Address - Fax:330-629-2271
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH18806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0754125Medicaid