Provider Demographics
NPI:1932250404
Name:JERSAK, JAMES DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DOUGLAS
Last Name:JERSAK
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 1:1722 S GLENSTONE AVE
Mailing Address - Street 2:EE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1519
Mailing Address - Country:US
Mailing Address - Phone:417-887-4435
Mailing Address - Fax:417-823-9436
Practice Address - Street 1:1722 S GLENSTONE AVE
Practice Address - Street 2:EE
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1519
Practice Address - Country:US
Practice Address - Phone:417-887-4435
Practice Address - Fax:417-823-9436
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13617122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist