Provider Demographics
NPI:1487611331
Name:SMALLEY, JACK OWEN (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:OWEN
Last Name:SMALLEY
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 1:2650 E PINON FRONTAGE RD BLDG 300
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5084
Mailing Address - Country:US
Mailing Address - Phone:505-327-3331
Mailing Address - Fax:505-327-0873
Practice Address - Street 1:2650 E PINON FRONTAGE RD BLDG 300
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5084
Practice Address - Country:US
Practice Address - Phone:505-327-3331
Practice Address - Fax:505-327-0873
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1918122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84279826Medicaid