Provider Demographics
NPI:1285986505
Name:OHANESIAN, JACK CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:CHARLES
Last Name:OHANESIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 S CLOVIS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-5316
Mailing Address - Country:US
Mailing Address - Phone:559-213-0932
Mailing Address - Fax:
Practice Address - Street 1:1879 E FIR AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3861
Practice Address - Country:US
Practice Address - Phone:559-322-6060
Practice Address - Fax:559-322-7888
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61812122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist