Provider Demographics
NPI:1932259397
Name:ELVIN, JACK R (DENTURIST)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:ELVIN
Suffix:
Gender:M
Credentials:DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 9TH AVE SE
Mailing Address - Street 2:#286
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-4872
Mailing Address - Country:US
Mailing Address - Phone:541-928-1955
Mailing Address - Fax:
Practice Address - Street 1:1113 HILL ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-3295
Practice Address - Country:US
Practice Address - Phone:541-928-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-609564122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR071696Medicaid