Provider Demographics
NPI:1265463467
Name:JACK, JERRY (DDS)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:JACK
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 1:555 W BENJAMIN HOLT DR
Mailing Address - Street 2:BUILDING B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:209-476-4700
Mailing Address - Fax:209-478-6890
Practice Address - Street 1:1740 N SERVICE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3307
Practice Address - Country:US
Practice Address - Phone:405-794-7200
Practice Address - Fax:405-794-2266
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice