Provider Demographics
NPI:1588891477
Name:CONDON, JACOB MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:CONDON
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 1:10 AVANTA WAY
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6873
Mailing Address - Country:US
Mailing Address - Phone:406-655-4210
Mailing Address - Fax:
Practice Address - Street 1:10 AVANTA WAY
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6873
Practice Address - Country:US
Practice Address - Phone:406-655-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1294122300000X
MTDEN-DEN-LIC-5935122300000X
MT59351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist