Provider Demographics
NPI:1699932285
Name:WEISS, JACK PHILLIP (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:PHILLIP
Last Name:WEISS
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 1:4704 CAHABA RIVER RD
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2344
Mailing Address - Country:US
Mailing Address - Phone:205-262-9855
Mailing Address - Fax:205-271-2128
Practice Address - Street 1:4704 CAHABA RIVER RD
Practice Address - Street 2:SUITE 2D
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-2344
Practice Address - Country:US
Practice Address - Phone:205-262-9855
Practice Address - Fax:205-271-2128
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist