Provider Demographics
NPI:1104138312
Name:NOEL, JAKE ROBERT (DMD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ROBERT
Last Name:NOEL
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 1:7022 SOUTHCREEK DR SE
Mailing Address - Street 2:
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-9185
Mailing Address - Country:US
Mailing Address - Phone:256-658-6637
Mailing Address - Fax:
Practice Address - Street 1:4004 BALMORAL DR SW STE B
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6402
Practice Address - Country:US
Practice Address - Phone:256-658-6637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5757122300000X
AL5757 C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist