Provider Demographics
NPI: | 1790768562 |
---|---|
Name: | KRAJEKIAN, JACK ISSAC (DMD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JACK |
Middle Name: | ISSAC |
Last Name: | KRAJEKIAN |
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: | 1215 VIRGINIA ST E |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLESTON |
Mailing Address - State: | WV |
Mailing Address - Zip Code: | 25301-2908 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 304-345-1092 |
Mailing Address - Fax: | 304-345-1095 |
Practice Address - Street 1: | 1215 VIRGINIA ST E |
Practice Address - Street 2: | |
Practice Address - City: | CHARLESTON |
Practice Address - State: | WV |
Practice Address - Zip Code: | 25301-2908 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-345-1092 |
Practice Address - Fax: | 304-345-1095 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-25 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WV | 3542 | 1223S0112X |
WV | 116 | 1223S0112X |
PA | DS036241 | 1223S0112X |
MA | 19714 | 1223S0112X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1223S0112X | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WV | 4002152000 | Medicaid | |
WV | U91934 | Medicare UPIN | |
WV | 4002152000 | Medicaid | |
WV | KR4092212 | Medicare ID - Type Unspecified |