Provider Demographics
NPI:1871632745
Name:SCOTT JACKS, DDS, INC
Entity Type:Organization
Organization Name:SCOTT JACKS, DDS, INC
Other - Org Name:CHILDREN'S DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-564-2444
Mailing Address - Street 1:2144 S BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-5123
Mailing Address - Country:US
Mailing Address - Phone:714-619-6280
Mailing Address - Fax:323-249-7565
Practice Address - Street 1:2144 S BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5123
Practice Address - Country:US
Practice Address - Phone:714-619-6280
Practice Address - Fax:323-249-7565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31668122300000X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98228-03OtherHF-GENERAL BILLING NO
CAG98229-03OtherHF-SPECIALTY BILLINIG NO
CAB24464-03Medicaid