Provider Demographics
NPI:1891539326
Name:CRIST, JACOB MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:CRIST
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 1:4465 VIGNY ST UNIT 1029
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-4466
Mailing Address - Country:US
Mailing Address - Phone:702-875-5799
Mailing Address - Fax:
Practice Address - Street 1:4465 VIGNY ST UNIT 1029
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-4466
Practice Address - Country:US
Practice Address - Phone:702-875-5799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13944804-99261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice