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General NPI Number Information
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NPI Number | 1326876988
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Entity Type | Organization
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Legal Business Name | DR JACKS DENTAL LOUNGE PLLC
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Dates
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Enumeration Date | 07/24/2024
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Last Update Date | 07/24/2024
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Provider Practice Location Address
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Address Line | 1363 N ASHLAND AVE STE 1
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City | CHICAGO
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State | IL
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Zip | 60622-5192
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Country | US
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Telephone | 773-343-3143
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Fax |
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Provider Business Mailing Address
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Address Line | 1363 N ASHLAND AVE STE 1
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City | CHICAGO
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State | IL
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Zip | 60622-5192
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Country | US
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Telephone | 773-343-3143
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. JACK GEISSLER
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Credential | DMD
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Telephone | 815-922-3635
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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