Provider Demographics
NPI:1790160687
Name:DUNHAM, JACOB
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:DUNHAM
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 1:7251 W 20TH ST BLDG H
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4625
Mailing Address - Country:US
Mailing Address - Phone:970-351-7153
Mailing Address - Fax:
Practice Address - Street 1:7251 W 20TH ST BLDG H
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4625
Practice Address - Country:US
Practice Address - Phone:970-351-7153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist