Provider Demographics
NPI:1528414398
Name:MINNILLO, JACK PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:PAUL
Last Name:MINNILLO
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 1:1012 STATE ROUTE 521 STE 202
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-8003
Mailing Address - Country:US
Mailing Address - Phone:740-417-9565
Mailing Address - Fax:
Practice Address - Street 1:1012 STATE ROUTE 521 STE 202
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-8003
Practice Address - Country:US
Practice Address - Phone:740-417-9565
Practice Address - Fax:614-443-8335
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.24727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist