Basic Information
| Provider Information | |||||||||
| NPI: | 1235594169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACK | ||||||||
| FirstName: | LORIELLE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 SUTTLE ST | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813038276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703352232 | ||||||||
| FaxNumber: | 9706772540 | ||||||||
| Practice Location | |||||||||
| Address1: | 2530 COLORADO AVE UNIT 1A | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813014761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703352442 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2015 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH002024003 | CO | Y | Dental Providers | Dental Hygienist |
No ID Information.