Provider Demographics
NPI:1821012303
Name:DEJACKMO, FRANK (DMD)
Entity Type:Individual
Prefix:DR
First Name:FRANK
Middle Name:
Last Name:DEJACKMO
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 1:128 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2925
Mailing Address - Country:US
Mailing Address - Phone:973-661-1075
Mailing Address - Fax:973-661-9686
Practice Address - Street 1:128 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2925
Practice Address - Country:US
Practice Address - Phone:973-661-1075
Practice Address - Fax:973-661-9686
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ105041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice