Provider Demographics
NPI:1285835355
Name:JASKOLKA, MICHAEL S (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:JASKOLKA
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-9331
Mailing Address - Fax:910-662-2403
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-667-9402
Practice Address - Fax:877-665-4450
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38971223S0112X
NC79931223S0112X
WV24111204E00000X
NC201400263204E00000X
NC2014-00263208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018601OtherMEDICAID MEDICAL
JA4294581Medicare PIN
WVP01067375OtherMEDICARE RAILROAD
WV3810018159Medicaid