Provider Demographics
NPI:1891940722
Name:NICHOLAS S. JAKSIC, DDS, INC.
Entity Type:Organization
Organization Name:NICHOLAS S. JAKSIC, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:JAKSIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-832-1181
Mailing Address - Street 1:1360 W 6TH ST STE 285
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3558
Mailing Address - Country:US
Mailing Address - Phone:310-832-1181
Mailing Address - Fax:310-832-3722
Practice Address - Street 1:1360 W 6TH ST STE 285
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3558
Practice Address - Country:US
Practice Address - Phone:310-832-1181
Practice Address - Fax:310-832-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty