Provider Demographics
NPI:1245344381
Name:MILLS, JACK TRACY
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:TRACY
Last Name:MILLS
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 1:5491 BREWER RD
Mailing Address - Street 2:
Mailing Address - City:SEALY
Mailing Address - State:TX
Mailing Address - Zip Code:77474
Mailing Address - Country:US
Mailing Address - Phone:979-885-3667
Mailing Address - Fax:979-885-3305
Practice Address - Street 1:1011 HIGHWAY 6 SOUTH
Practice Address - Street 2:STE 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077
Practice Address - Country:US
Practice Address - Phone:281-556-1606
Practice Address - Fax:281-556-1438
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX98691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice