Provider Demographics
NPI:1114396579
Name:PROULX, JACQUELYN FAITH (DMD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:FAITH
Last Name:PROULX
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:FAITH
Other - Last Name:KASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2030 ELMEN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-6107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 PICKNEY BLVD.
Practice Address - Street 2:NAVAL HOSPITAL BEAUFORT
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:941-345-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002026431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice