Basic Information
Provider Information
NPI: 1285292078
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MALONE
FirstName: JACOB
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 15954 RIVERS EDGE DR
Address2:  
City: HAYWARD
State: WI
PostalCode: 548437800
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 820 ARBUTUS AVE
Address2:  
City: OCONTO
State: WI
PostalCode: 541532004
CountryCode: US
TelephoneNumber: 7156342541
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/05/2019
LastUpdateDate: 06/05/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X1002093WIY Dental ProvidersDentistGeneral Practice

No ID Information.


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