1285656645 NPI number — DR. NICHOLAS STEPHEN JAKSIC DDS

Table of content: DR. NICHOLAS STEPHEN JAKSIC DDS (NPI 1285656645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285656645 NPI number — DR. NICHOLAS STEPHEN JAKSIC DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAKSIC
Provider First Name:
NICHOLAS
Provider Middle Name:
STEPHEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JAKSIC
Provider Other First Name:
NICHOLAS
Provider Other Middle Name:
STEPHEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1285656645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1360 WEST 6TH STREET
Provider Second Line Business Mailing Address:
SUITE 285
Provider Business Mailing Address City Name:
SAN PEDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-832-1181
Provider Business Mailing Address Fax Number:
310-832-3722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1360 WEST 6TH STREET
Provider Second Line Business Practice Location Address:
SUITE 285
Provider Business Practice Location Address City Name:
SAN PEDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-832-1181
Provider Business Practice Location Address Fax Number:
310-832-3722
Provider Enumeration Date:
07/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  38058 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)