Provider Demographics
NPI:1427154020
Name:CHURCHILL, JACK LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:LOUIS
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14615 13TH PL N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4526
Mailing Address - Country:US
Mailing Address - Phone:763-475-3710
Mailing Address - Fax:763-475-2784
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:1427 MEDICAL ARTS BLDG
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-333-8988
Practice Address - Fax:612-339-3618
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN87471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice