Provider Demographics
NPI:1992187389
Name:DIEBOLD, JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DIEBOLD
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 1068
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775-1068
Mailing Address - Country:US
Mailing Address - Phone:225-635-4707
Mailing Address - Fax:225-635-2172
Practice Address - Street 1:7181 US HIGHWAY 61
Practice Address - Street 2:SUITE 10
Practice Address - City:ST. FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775
Practice Address - Country:US
Practice Address - Phone:225-635-4707
Practice Address - Fax:225-635-2172
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6554122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist