Healthcare Provider Details

I. General information

NPI: 1871577767
Provider Name (Legal Business Name): CYNTHIA JAKUBAS SHALOM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/04/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1445
FPO AP
96350
JP

IV. Provider business mailing address

PSC 475 BOX 1445
FPO AP
96350
JP

V. Phone/Fax

Practice location:
  • Phone: 2437951
  • Fax:
Mailing address:
  • Phone: 2437951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6067
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: