Individual
DR. LARRY LEE JACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
404 E 7TH ST, LEADVILLE, CO 80461-3131
(410) 980-5433
Mailing address
PO BOX 476, LEADVILLE, CO 80461-0476
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
7752
CO
122300000X
Dentist
9327
MD
Other
Enumeration date
01/27/2013
Last updated
01/27/2013
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