Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 200916780 | MO |
N | 122300000X | Dentist | 62350 | CA |
Y | 1223X0400X | Orthodontists | 29374 | TX |
NPI | 1063645745 |
---|---|
Provider Name | Mrs. Knieeka Shanell Jake-Pacheco |
First Address | Bryan, TX 77802-3124 |
Second Address | Bryan, TX 77802 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2009 |
Last Update Date | 28/08/2018 |