Provider Demographics
NPI:1194928614
Name:SCOTT JACKS, DDS, INC
Entity type:Organization
Organization Name:SCOTT JACKS, DDS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-564-2444
Mailing Address - Street 1:4354 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6237
Mailing Address - Country:US
Mailing Address - Phone:323-564-2444
Mailing Address - Fax:323-249-7565
Practice Address - Street 1:4354 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6237
Practice Address - Country:US
Practice Address - Phone:323-564-2444
Practice Address - Fax:323-249-7565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA316681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB24464-01Medicaid