Provider Demographics
NPI:1295719201
Name:KILGORE, JACK LLOYD JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:LLOYD
Last Name:KILGORE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 BEAVER DAM CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-3122
Mailing Address - Country:US
Mailing Address - Phone:803-699-9697
Mailing Address - Fax:803-736-5358
Practice Address - Street 1:41 BEAVER DAM CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-3122
Practice Address - Country:US
Practice Address - Phone:803-699-9697
Practice Address - Fax:803-736-5358
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist