Provider Demographics
NPI:1487901740
Name:LOUIE, JACK (DDS)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LOUIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 STUART ST UNIT 18A
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5668
Mailing Address - Country:US
Mailing Address - Phone:901-258-3188
Mailing Address - Fax:
Practice Address - Street 1:110 STUART ST UNIT 18A
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5668
Practice Address - Country:US
Practice Address - Phone:901-258-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2025-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT143511223D0004X
MADN18597501223P0221X, 1223D0004X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
No1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program