Provider Demographics
NPI:1467801068
Name:DAIGREPONT, JACK
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:DAIGREPONT
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 1:239 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROUNDUP
Mailing Address - State:MT
Mailing Address - Zip Code:59072-2735
Mailing Address - Country:US
Mailing Address - Phone:406-323-1234
Mailing Address - Fax:
Practice Address - Street 1:2376 MAIN ST STE 812
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-4018
Practice Address - Country:US
Practice Address - Phone:406-656-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT216481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice