Provider Demographics
NPI:1679973879
Name:DENIAKOS, JACOB A (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:A
Last Name:DENIAKOS
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 1:300 S. TWINING STREET, BLDG 760
Mailing Address - Street 2:42D MEDICAL GROUP
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112
Mailing Address - Country:US
Mailing Address - Phone:334-953-5143
Mailing Address - Fax:334-953-8607
Practice Address - Street 1:300 S. TWINING STREET, BLDG 760
Practice Address - Street 2:42D MEDICAL GROUP
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-8607
Practice Address - Fax:334-953-8607
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6439122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist