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General NPI Number Information
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NPI Number | 1366549545
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Entity Type | Organization
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Legal Business Name | SCOTT JACKS DDS INC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 09/23/2015
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Provider Practice Location Address
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Address Line | 4444 TWEEDY BLVD
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City | SOUTH GATE
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State | CA
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Zip | 90280-6304
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Country | US
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Telephone | 323-564-2444
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Fax | 564-249-7565
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Provider Business Mailing Address
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Address Line | 4444 TWEEDY BLVD
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City | SOUTH GATE
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State | CA
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Zip | 90280-6304
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Country | US
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Telephone | 323-564-2444
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Fax | 564-249-7565
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERRY DAVID MINSKY
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Credential | DDS
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Telephone | 323-564-2444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 31668
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 31668
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 31668
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 31668
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 31668
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 31668
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License Number State | AZ
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