Provider Demographics
NPI:1982791166
Name:LEVI, JACK (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:LEVI
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:PO BOX 2077
Mailing Address - Street 2:185 CEDAR LANE
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1477
Mailing Address - Country:US
Mailing Address - Phone:201-385-5400
Mailing Address - Fax:201-969-1144
Practice Address - Street 1:185 CEDAR LN
Practice Address - Street 2:SUITE L7
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4316
Practice Address - Country:US
Practice Address - Phone:201-385-5400
Practice Address - Fax:201-969-1144
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-07
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ83401223E0200X
NY0264991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics