Provider Demographics
NPI:1083458624
Name:WINDAUER, JACOB ROBERT (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:WINDAUER
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 1:421 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-2123
Mailing Address - Country:US
Mailing Address - Phone:406-883-1343
Mailing Address - Fax:
Practice Address - Street 1:421 MAIN ST
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2123
Practice Address - Country:US
Practice Address - Phone:406-883-1343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-284401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice