Provider Demographics
NPI:1003544842
Name:MACK, JACOB (DMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:MACK
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 1:4175 S ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS MONTHAN AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707-4402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMO AVE
Practice Address - Street 2:
Practice Address - City:DAVIS MONTHAN AFB
Practice Address - State:AZ
Practice Address - Zip Code:85707-4402
Practice Address - Country:US
Practice Address - Phone:719-333-5192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO663620651223G0001X
390200000X
CODEN.002053411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program