Provider Demographics
NPI:1275150658
Name:HOLTZCLAW, JACOB WILEY-BLUE (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WILEY-BLUE
Last Name:HOLTZCLAW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 PHILEMA RD APT 15
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1245
Mailing Address - Country:US
Mailing Address - Phone:770-815-0655
Mailing Address - Fax:
Practice Address - Street 1:1725 DAWSON RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3362
Practice Address - Country:US
Practice Address - Phone:229-883-7891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0160801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice