Healthcare Provider Details

I. General information

NPI: 1538130752
Provider Name (Legal Business Name): RYAN MICHAEL JACK D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 06/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8580 SCARBOROUGH DR #200
COLORADO SPRINGS CO
80920-7583
US

IV. Provider business mailing address

8580 SCARBOROUGH DR #200
COLORADO SPRINGS CO
80920-7583
US

V. Phone/Fax

Practice location:
  • Phone: 719-282-6600
  • Fax:
Mailing address:
  • Phone: 719-282-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD-3585
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN18177
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number10046
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: