Provider Demographics
NPI:1942327838
Name:PUGH, JACK Y (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:Y
Last Name:PUGH
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:PO BOX 311870
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331-1870
Mailing Address - Country:US
Mailing Address - Phone:334-347-6456
Mailing Address - Fax:334-393-3817
Practice Address - Street 1:442 GLOVER AVE
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330
Practice Address - Country:US
Practice Address - Phone:334-347-6456
Practice Address - Fax:334-393-3817
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2582 C.S.1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-34127OtherBLUE CROSS BLUE SHIELD