Provider Demographics
NPI:1447375720
Name:SELLERS, JACK N (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:N
Last Name:SELLERS
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 1:103 NW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1700
Mailing Address - Country:US
Mailing Address - Phone:918-967-4609
Mailing Address - Fax:918-967-9041
Practice Address - Street 1:103 NW 9TH ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1700
Practice Address - Country:US
Practice Address - Phone:918-967-4609
Practice Address - Fax:918-967-9041
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice