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General NPI Number Information
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NPI Number | 1467206060
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Entity Type | Individual
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Provider Name | JESUS ANTONIO SANTIAGO JR.
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Gender | Male
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Dates
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Enumeration Date | 04/11/2024
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 370 TALBERT RD, STE 300
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City | MOORESVILLE
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State | NC
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Zip | 28117
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Country | US
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Telephone | 954-494-2103
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Fax |
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Provider Business Mailing Address
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Address Line | 525 E 21ST ST APT 105
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City | CHARLOTTE
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State | NC
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Zip | 28206-3880
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Country | US
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Telephone | 954-494-2103
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 13946
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License Number State | NC
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