Provider Demographics
NPI:1952481194
Name:HOOVER, JACK LEWIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEWIS
Last Name:HOOVER
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 1:117 W MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2667
Mailing Address - Country:US
Mailing Address - Phone:765-664-0028
Mailing Address - Fax:765-668-3658
Practice Address - Street 1:117 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2667
Practice Address - Country:US
Practice Address - Phone:765-664-0028
Practice Address - Fax:765-668-3658
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120083161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice