Provider Demographics
NPI:1134417785
Name:MERCKE, JACK R (DMD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:MERCKE
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 1:1779 PATRICK DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41005-7302
Mailing Address - Country:US
Mailing Address - Phone:859-689-2730
Mailing Address - Fax:859-689-2731
Practice Address - Street 1:1779 PATRICK DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-7302
Practice Address - Country:US
Practice Address - Phone:859-689-2730
Practice Address - Fax:859-689-2731
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9094122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist