Healthcare Provider Details

I. General information

NPI: 1093554818
Provider Name (Legal Business Name): JACOB SCHOLZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 AMERICAN EAGLE DR
SLINGER WI
53086-9167
US

IV. Provider business mailing address

6244 N BAY RIDGE AVE
WHITEFISH BAY WI
53217-4327
US

V. Phone/Fax

Practice location:
  • Phone: 262-644-7400
  • Fax:
Mailing address:
  • Phone: 414-248-1363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001494-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: