Provider Demographics
NPI:1104046556
Name:BACKS, JACK FREDRICK (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:FREDRICK
Last Name:BACKS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 STATE ROUTE 100 W
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041-1526
Mailing Address - Country:US
Mailing Address - Phone:573-486-3500
Mailing Address - Fax:573-486-3166
Practice Address - Street 1:154 STATE ROUTE 100 W
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1526
Practice Address - Country:US
Practice Address - Phone:573-486-3500
Practice Address - Fax:573-486-3166
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE 0150821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice