Provider Demographics
NPI:1982819843
Name:NASH, JACK WESTON
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WESTON
Last Name:NASH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-2591
Mailing Address - Country:US
Mailing Address - Phone:989-752-1200
Mailing Address - Fax:989-752-2481
Practice Address - Street 1:1320 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2591
Practice Address - Country:US
Practice Address - Phone:989-752-1200
Practice Address - Fax:989-752-2481
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011744122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1704648Medicaid