MEDICARE: DR. JACK ALKON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4577	CT

General Provider Information

NPI Number	:	1104820505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK ALKON D.M.D.

Provider Business Mailing Address
First Line	:	51 N MAIN ST
Second Line	:
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-2537
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 N MAIN ST
Second Line	:
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-2537
Country	:	US
Telephone Number	:	860-621-6321
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	07/08/2007

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