Provider Demographics
NPI:1205451754
Name:WOOD, JACOB (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3013
Mailing Address - Country:US
Mailing Address - Phone:406-752-2372
Mailing Address - Fax:
Practice Address - Street 1:221 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3013
Practice Address - Country:US
Practice Address - Phone:406-752-2372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT236221223G0001X
OK7283122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist