Healthcare Provider Details

I. General information

NPI: 1285835355
Provider Name (Legal Business Name): MICHAEL S. JASKOLKA DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-9402
  • Fax: 877-665-4450
Mailing address:
  • Phone: 910-662-9331
  • Fax: 910-662-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3897
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7993
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number24111
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number201400263
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2014-00263
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: