Healthcare Provider Details

I. General information

NPI: 1295416139
Provider Name (Legal Business Name): JACOB JUDD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7721 W 21ST ST N
WICHITA KS
67205-1737
US

IV. Provider business mailing address

652 W 163RD ST APT 28
NEW YORK NY
10032-4515
US

V. Phone/Fax

Practice location:
  • Phone: 316-681-1099
  • Fax: 316-613-2417
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number62079
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02950800
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number929
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: