MEDICARE: SCOTT JACKS, DDS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	31668	CA
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	31668	CA
3	122300000X	Dentist	31668	CA

General Provider Information

NPI Number	:	1588703458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT JACKS, DDS, INC

Provider Business Mailing Address
First Line	:	2156 E LINCOLN AVE
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92806-4104
Country	:	US
Telephone Number	:	714-399-3140
Fax Number	:	323-249-7565

Provider Business Practice Location Address
First Line	:	2156 E LINCOLN AVE
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92806-4104
Country	:	US
Telephone Number	:	714-399-3140
Fax Number	:	323-249-7565

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JERRY DAVID MINSKY
Credential	:	DDS
Telephone Number	:	323-564-2444

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	09/23/2015

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