Provider Demographics
NPI:1811992332
Name:KING, JACK DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:DOUGLAS
Last Name:KING
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 1:3215 MEADOW RUE LN
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4562
Mailing Address - Country:US
Mailing Address - Phone:704-872-1702
Mailing Address - Fax:
Practice Address - Street 1:1706 DAVIE AVE
Practice Address - Street 2:STE B
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3589
Practice Address - Country:US
Practice Address - Phone:704-873-1968
Practice Address - Fax:704-872-5841
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice