=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740021427
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB VIEAU DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2024
-----------------------------------------------------
Last Update Date | 06/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6297 DIXIE HWY
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48722-9635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-921-5390
-----------------------------------------------------
Fax | 833-448-3204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 LAPEER AVE
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48607-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-759-6464
-----------------------------------------------------
Fax | 989-399-8233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901602077
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------