Healthcare Provider Details

I. General information

NPI: 1851213326
Provider Name (Legal Business Name): ANDREW JACOB DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 KINGSTON TER
GREEN BAY WI
54302-5405
US

IV. Provider business mailing address

1401 KINGSTON TER
GREEN BAY WI
54302-5405
US

V. Phone/Fax

Practice location:
  • Phone: 920-465-4477
  • Fax: 920-465-4479
Mailing address:
  • Phone: 920-465-4477
  • Fax: 920-465-4479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6002270-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: