Healthcare Provider Details

I. General information

NPI: 1336542851
Provider Name (Legal Business Name): SCOTT JACKS, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4138 MAINE AVE STE M2
BALDWIN PARK CA
91706-3302
US

IV. Provider business mailing address

4444 TWEEDY BLVD
SOUTH GATE CA
90280-6304
US

V. Phone/Fax

Practice location:
  • Phone: 323-564-2444
  • Fax: 323-923-1088
Mailing address:
  • Phone: 323-564-2444
  • Fax: 323-923-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number24464
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number31668
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number31668
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JERRY DAVID MINSKY
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 323-564-2444