Basic Information
| Provider Information | |||||||||
| NPI: | 1124755202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENDON | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 LYNN DR # 201 | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778013322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062061339 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1509 EMERALD PKWY STE 105 | ||||||||
| Address2: | |||||||||
| City: | COLLEGE STATION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778455502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9796968681 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2022 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 38895 | TX | Y | Dental Providers | Dentist |
No ID Information.