Provider Demographics
NPI:1437837689
Name:CALDWELL, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CALDWELL
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 1:1067 TWINING DRIVE
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AIR FORCE BASE
Mailing Address - State:LA
Mailing Address - Zip Code:71112
Mailing Address - Country:US
Mailing Address - Phone:318-456-6718
Mailing Address - Fax:
Practice Address - Street 1:1067 TWINING DRIVE
Practice Address - Street 2:
Practice Address - City:BARKSDALE AIR FORCE BASE
Practice Address - State:LA
Practice Address - Zip Code:71112
Practice Address - Country:US
Practice Address - Phone:318-456-6718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist