Provider Demographics
NPI:1922237379
Name:HASLEM, JACOB A (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:HASLEM
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:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045
Mailing Address - Country:US
Mailing Address - Phone:801-318-7475
Mailing Address - Fax:866-667-3006
Practice Address - Street 1:167 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:801-318-7475
Practice Address - Fax:866-667-3006
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist