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General NPI Number Information
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NPI Number | 1902485725
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Entity Type | Individual
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Provider Name | JACOB ROBERT WALLOCK DDS
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Gender | Male
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Dates
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Enumeration Date | 04/07/2021
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Last Update Date | 06/17/2021
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Provider Practice Location Address
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Address Line | 145 S MARR ST
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City | FOND DU LAC
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State | WI
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Zip | 54935-4408
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Country | US
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Telephone | 920-922-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 W WISCONSIN AVE
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City | MILWAUKEE
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State | WI
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Zip | 53233-2186
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Country | US
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Telephone | 414-322-9456
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1002568-15
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License Number State | WI
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