Provider Demographics
NPI:1598118598
Name:SLUDER, JACOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SLUDER
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 1:328 CHESTER ST SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2041
Mailing Address - Country:US
Mailing Address - Phone:423-762-1903
Mailing Address - Fax:
Practice Address - Street 1:113 TOWNE LAKE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4853
Practice Address - Country:US
Practice Address - Phone:770-928-3055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist