Provider Demographics
NPI:1013051150
Name:JACK E. KING DDS INC
Entity Type:Organization
Organization Name:JACK E. KING DDS INC
Other - Org Name:KING AND MAYERSON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-433-0830
Mailing Address - Street 1:6460 FAR HILLS AVENUE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459
Mailing Address - Country:US
Mailing Address - Phone:937-433-0830
Mailing Address - Fax:937-433-9530
Practice Address - Street 1:6460 FAR HILLS AVENUE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:937-433-0830
Practice Address - Fax:937-433-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300135121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty