Healthcare Provider Details

I. General information

NPI: 1790768562
Provider Name (Legal Business Name): JACK ISSAC KRAJEKIAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 VIRGINIA ST E
CHARLESTON WV
25301-2908
US

IV. Provider business mailing address

1215 VIRGINIA ST E
CHARLESTON WV
25301-2908
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-1092
  • Fax: 304-345-1095
Mailing address:
  • Phone: 304-345-1092
  • Fax: 304-345-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3542
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number116
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS036241
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19714
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: