Basic Information
| Provider Information | |||||||||
| NPI: | 1679973879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENIAKOS | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S. TWINING STREET, BLDG 760 | ||||||||
| Address2: | 42D MEDICAL GROUP | ||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349535143 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S. TWINING STREET, BLDG 760 | ||||||||
| Address2: | 42D MEDICAL GROUP | ||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349538607 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2014 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 6439 | LA | Y | Dental Providers | Dentist |
No ID Information.