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General NPI Number Information
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NPI Number | 1538242482
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Entity Type | Individual
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Provider Name | MICHAEL ALAN JACK DDS ,MS
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Gender | Male
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 822 PORTAGE TRAIL
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City | CUYAHOGA FALLS
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State | OH
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Zip | 44221
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Country | US
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Telephone | 330-929-2853
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Fax | 330-929-3821
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Provider Business Mailing Address
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Address Line | 610 FIXLER DRIVE
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City | WADSWORTH
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State | OH
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Zip | 44281
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Country | US
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Telephone | 330-334-1967
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 17357
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License Number State | OH
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