Provider Demographics
NPI:1760485015
Name:SACKS, JEFFREY CLYDE (DMD,MS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CLYDE
Last Name:SACKS
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BOYLSTON STREET
Mailing Address - Street 2:SUITE 305
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467
Mailing Address - Country:US
Mailing Address - Phone:617-731-8888
Mailing Address - Fax:617-731-3107
Practice Address - Street 1:200 BOYLSTON ST
Practice Address - Street 2:SUITE 305
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2012
Practice Address - Country:US
Practice Address - Phone:617-731-8888
Practice Address - Fax:617-731-3107
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17089204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX05901Medicare ID - Type Unspecified
MAX05901Medicare UPIN