Provider Demographics
NPI:1700810231
Name:GROOVER, JACK W JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:GROOVER
Suffix:JR
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 1:711 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4810
Mailing Address - Country:US
Mailing Address - Phone:912-354-9541
Mailing Address - Fax:912-354-3950
Practice Address - Street 1:711 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4810
Practice Address - Country:US
Practice Address - Phone:912-354-9541
Practice Address - Fax:912-354-3950
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice