Healthcare Provider Details

I. General information

NPI: 1841090479
Provider Name (Legal Business Name): JACOB I DIAZ-CASTANEDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2025
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1386 GRAY HWY
MACON GA
31211-1952
US

IV. Provider business mailing address

4358 RIVERSIDE DR APT 1301
MACON GA
31210-1783
US

V. Phone/Fax

Practice location:
  • Phone: 478-992-1500
  • Fax:
Mailing address:
  • Phone: 850-737-1271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123923
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401419527
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: