Provider Demographics
NPI:1013694462
Name:STINSON, JACOB TANT (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:TANT
Last Name:STINSON
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 1:1551 W PARKS HWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6933
Mailing Address - Country:US
Mailing Address - Phone:907-357-6684
Mailing Address - Fax:
Practice Address - Street 1:1551 W PARKS HWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6933
Practice Address - Country:US
Practice Address - Phone:907-357-6684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK210383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist