Provider Demographics
NPI:1134571755
Name:JACOME, MIGUEL JR (EFDA ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:JACOME
Suffix:JR
Gender:M
Credentials:EFDA ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19710 13TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8046
Mailing Address - Country:US
Mailing Address - Phone:208-818-6238
Mailing Address - Fax:
Practice Address - Street 1:N DIVISION ST BLDG 2103
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-966-7814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant