=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700290483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB FLEIG DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2014
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 HIGHWAY 61 S
-----------------------------------------------------
City | NATCHEZ
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39120-5216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-446-9099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 MCARTHUR CT
-----------------------------------------------------
City | YOUNGSVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70592-6660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-501-2871
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3760-14
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3760-14
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6529
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------