Provider Demographics
NPI:1346629516
Name:JUDY, JACOB MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MARK
Last Name:JUDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 CLIFFHANGER WAY
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-6420
Mailing Address - Country:US
Mailing Address - Phone:740-450-3636
Mailing Address - Fax:
Practice Address - Street 1:3555 CLIFFHANGER WAY
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701
Practice Address - Country:US
Practice Address - Phone:740-450-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.024454122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist