Provider Demographics
NPI:1063645745
Name:JAKE-PACHECO, KNIEEKA SHANELL (DMD)
Entity Type:Individual
Prefix:MRS
First Name:KNIEEKA
Middle Name:SHANELL
Last Name:JAKE-PACHECO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:KNIEEKA
Other - Middle Name:SHANELL
Other - Last Name:JAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3111 S TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3124
Mailing Address - Country:US
Mailing Address - Phone:979-446-0270
Mailing Address - Fax:
Practice Address - Street 1:3111 S TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802
Practice Address - Country:US
Practice Address - Phone:979-446-0270
Practice Address - Fax:979-775-7641
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62350122300000X
MO200916780122300000X
TX293741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist