Provider Demographics
NPI:1790768562
Name:KRAJEKIAN, JACK ISSAC (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ISSAC
Last Name:KRAJEKIAN
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 1:1215 VIRGINIA ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2908
Mailing Address - Country:US
Mailing Address - Phone:304-345-1092
Mailing Address - Fax:304-345-1095
Practice Address - Street 1:1215 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2908
Practice Address - Country:US
Practice Address - Phone:304-345-1092
Practice Address - Fax:304-345-1095
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35421223S0112X
WV1161223S0112X
PADS0362411223S0112X
MA197141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002152000Medicaid
WVU91934Medicare UPIN
WV4002152000Medicaid
WVKR4092212Medicare ID - Type Unspecified