Provider Demographics
NPI:1831291277
Name:JACK D GRIFFIN JR DMD PC
Entity Type:Organization
Organization Name:JACK D GRIFFIN JR DMD PC
Other - Org Name:EUREKA SMILE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD PC FAGD
Authorized Official - Phone:636-938-6241
Mailing Address - Street 1:18 HILLTOP VILLAGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025
Mailing Address - Country:US
Mailing Address - Phone:636-938-6241
Mailing Address - Fax:636-938-7941
Practice Address - Street 1:18 HILLTOP VILLAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-3921
Practice Address - Country:US
Practice Address - Phone:636-938-6241
Practice Address - Fax:636-938-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014900122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty