Healthcare Provider Details

I. General information

NPI: 1659486082
Provider Name (Legal Business Name): JACOB LAWRENCE KITSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-8628
  • Fax:
Mailing address:
  • Phone: 210-292-8628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5469
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: