Provider Demographics
NPI:1851443543
Name:MIRCHIN, JACK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:MIRCHIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5642 SHIELDS DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-3573
Mailing Address - Country:US
Mailing Address - Phone:301-530-1203
Mailing Address - Fax:
Practice Address - Street 1:5642 SHIELDS DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-3573
Practice Address - Country:US
Practice Address - Phone:301-530-1203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD71211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice