Provider Demographics
NPI:1417578717
Name:LAXER, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:LAXER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29404-4704
Mailing Address - Country:US
Mailing Address - Phone:843-963-6880
Mailing Address - Fax:
Practice Address - Street 1:204 W HILL BLVD
Practice Address - Street 2:
Practice Address - City:JOINT BASE CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29404-4704
Practice Address - Country:US
Practice Address - Phone:843-963-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice