Basic Information
| Provider Information | |||||||||
| NPI: | 1487901740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOUIE | ||||||||
| FirstName: | JACK | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3550 GRANDVIEW PKWY APT 538 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352431967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012583188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1407 W 84TH AVE | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802604781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202144746 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2012 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | 6003 | AL | N | Dental Providers | Dentist | 122300000X | DEN.00202388 | CO | Y | Dental Providers | Dentist |
No ID Information.