Healthcare Provider Details

I. General information

NPI: 1366549545
Provider Name (Legal Business Name): SCOTT JACKS DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 TWEEDY BLVD
SOUTH GATE CA
90280-6304
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: 564-249-7565
Mailing address:
  • Phone: 323-564-2444
  • Fax: 564-249-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number31668
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number31668
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number31668
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number31668
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number31668
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number31668
License Number StateAZ

VIII. Authorized Official

Name: DR. JERRY DAVID MINSKY
Title or Position: OWNER
Credential: DDS
Phone: 323-564-2444