Healthcare Provider Details

I. General information

NPI: 1104648468
Provider Name (Legal Business Name): JK DENTAL CONSULTANTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 EAST ST STE 2500
METHUEN MA
01844-4519
US

IV. Provider business mailing address

320 MIDDLESEX AVE UNIT C208
MEDFORD MA
02155-5084
US

V. Phone/Fax

Practice location:
  • Phone: 978-788-9303
  • Fax:
Mailing address:
  • Phone: 815-995-2852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. VAIBHAV JAGAD
Title or Position: MANAGER
Credential: DMD
Phone: 815-995-2852