Provider Demographics
NPI:1780626945
Name:STEWART, JACK CRAIG (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:CRAIG
Last Name:STEWART
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 1:615 HOLIDAY PLAZA
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:KS
Mailing Address - Zip Code:66043
Mailing Address - Country:US
Mailing Address - Phone:913-727-6700
Mailing Address - Fax:
Practice Address - Street 1:615 HOLIDAY PLAZA
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043
Practice Address - Country:US
Practice Address - Phone:913-727-6700
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS69131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS017332OtherBLUE CROSS
MO23059016OtherBLUE CROSS BLUE SHIELD