Provider Demographics
NPI:1902053200
Name:SUMMERLIN, JACK DONALD III (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DONALD
Last Name:SUMMERLIN
Suffix:III
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 1:3351 N MERIDIAN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4675
Mailing Address - Country:US
Mailing Address - Phone:317-926-5200
Mailing Address - Fax:
Practice Address - Street 1:3351 N MERIDIAN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4675
Practice Address - Country:US
Practice Address - Phone:317-926-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011175A122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist