Provider Demographics
NPI:1295928844
Name:STEVEN C. JACKS, D.D.S., INC.
Entity type:Organization
Organization Name:STEVEN C. JACKS, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-277-8959
Mailing Address - Street 1:7111 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2565
Mailing Address - Country:US
Mailing Address - Phone:937-277-8959
Mailing Address - Fax:937-277-6161
Practice Address - Street 1:7111 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2565
Practice Address - Country:US
Practice Address - Phone:937-277-8959
Practice Address - Fax:937-277-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH197451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2005092Medicaid
OHST9298981Medicare PIN
OHU72346Medicare UPIN