Provider Demographics
NPI:1760697577
Name:GARVIN, JACK G (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:G
Last Name:GARVIN
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 1:620 SE OAK ST STE C
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4160
Mailing Address - Country:US
Mailing Address - Phone:503-648-0727
Mailing Address - Fax:503-648-0644
Practice Address - Street 1:620 SE OAK ST STE C
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4160
Practice Address - Country:US
Practice Address - Phone:503-648-0727
Practice Address - Fax:503-648-0644
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR48261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice