MEDICARE: DR. JOHN ROBERT JAICKS DMD

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	122300000X	Dentist	30.026526	OH
2	122300000X	Dentist	DT-3135	HI

General Provider Information

NPI Number	:	1508433822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ROBERT JAICKS DMD

Provider Business Mailing Address
First Line	:	590 FARRINGTON HWY UNIT 523
Second Line	:
City	:	KAPOLEI
State	:	HI
Zip	:	96707-2034
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 FARRINGTON HWY UNIT 523
Second Line	:
City	:	KAPOLEI
State	:	HI
Zip	:	96707-2034
Country	:	US
Telephone Number	:	808-674-9988
Fax Number	:

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

Provider Enumeration Date	:	06/06/2021
Last Update Date	:	01/09/2024

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