Provider Demographics
NPI:1588708937
Name:JACK E. GORIS D.D.S.,PC
Entity type:Organization
Organization Name:JACK E. GORIS D.D.S.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:GORIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-753-4542
Mailing Address - Street 1:1821 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1200
Mailing Address - Country:US
Mailing Address - Phone:574-753-4542
Mailing Address - Fax:574-722-5059
Practice Address - Street 1:1821 CHASE RD
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1200
Practice Address - Country:US
Practice Address - Phone:574-753-4542
Practice Address - Fax:574-722-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120083891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty