Basic Information
| Provider Information | |||||||||
| NPI: | 1285835355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JASKOLKA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936857 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311936857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106629331 | ||||||||
| FaxNumber: | 9106622403 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106679402 | ||||||||
| FaxNumber: | 8776654450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 3897 | WV | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 7993 | NC | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | 24111 | WV | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 204E00000X | 201400263 | NC | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 208600000X | 2014-00263 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.