Provider Demographics
NPI:1669215380
Name:KALLOCH, JACK (DMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KALLOCH
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 1:810 E BROWN DEER RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-3549
Practice Address - Country:US
Practice Address - Phone:956-380-2482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40609122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist