Provider Demographics
NPI:1285235234
Name:SUN, JACK (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:SUN
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 1:5404 NAVE DR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6404
Mailing Address - Country:US
Mailing Address - Phone:408-691-9238
Mailing Address - Fax:
Practice Address - Street 1:5404 NAVE DR
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6404
Practice Address - Country:US
Practice Address - Phone:415-234-6261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105270122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist