Provider Demographics
NPI:1770672156
Name:HEMELSTRAND, JACK ALAN (DMD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALAN
Last Name:HEMELSTRAND
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 1:60 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7222
Mailing Address - Country:US
Mailing Address - Phone:503-665-3116
Mailing Address - Fax:503-665-3117
Practice Address - Street 1:60 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7222
Practice Address - Country:US
Practice Address - Phone:503-665-3116
Practice Address - Fax:503-665-3117
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist