MEDICARE: JACOB DENT DDS DENTISTS OF LAKE CHARLES A PROFFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1922511070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACOB DENT DDS DENTISTS OF LAKE CHARLES A PROFFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:	714-845-8500
Fax Number	:	303-952-0892

Provider Business Practice Location Address
First Line	:	4750 NELSON RD STE 100
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-5382
Country	:	US
Telephone Number	:	337-210-8864
Fax Number	:	337-210-8864

Authorized Official
Title or Position	:	OWNER
Name	:	JACOB DENT
Credential	:
Telephone Number	:	337-210-8664

Provider Enumeration Date	:	11/13/2017
Last Update Date	:	05/11/2022

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