Provider Demographics
NPI:1700318060
Name:MIMMS, JAKE RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:RYAN
Last Name:MIMMS
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 1:8263 MADISON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2051
Mailing Address - Country:US
Mailing Address - Phone:256-774-7228
Mailing Address - Fax:
Practice Address - Street 1:8263 MADISON BLVD STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2051
Practice Address - Country:US
Practice Address - Phone:256-774-7228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL64321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program