Provider Demographics
NPI:1013902980
Name:HANCOCK, JACK HAYNES (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:HAYNES
Last Name:HANCOCK
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 1:10 ENTERPRISE BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6301
Mailing Address - Country:US
Mailing Address - Phone:864-234-8811
Mailing Address - Fax:864-234-8844
Practice Address - Street 1:10 ENTERPRISE BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6301
Practice Address - Country:US
Practice Address - Phone:864-234-8811
Practice Address - Fax:864-234-8844
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15881223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ15889Medicaid