Provider Demographics
NPI:1396427381
Name:DESSE, JACK (DMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DESSE
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 1:1610 SHURTLEFF CT
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4067
Mailing Address - Country:US
Mailing Address - Phone:618-978-1809
Mailing Address - Fax:
Practice Address - Street 1:1809 HOMER M ADAMS PKWY UNIT A
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5606
Practice Address - Country:US
Practice Address - Phone:618-440-3758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist