Provider Demographics
NPI:1124248406
Name:KAHLA, JODI LEE
Entity type:Individual
Prefix:DR
First Name:JODI
Middle Name:LEE
Last Name:KAHLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 S WHEELER ST STE E
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-5600
Mailing Address - Country:US
Mailing Address - Phone:409-384-5091
Mailing Address - Fax:409-384-5046
Practice Address - Street 1:2051-E SOUTH WHEELER
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5600
Practice Address - Country:US
Practice Address - Phone:409-384-5091
Practice Address - Fax:409-384-5046
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice