Basic Information
| Provider Information | |||||||||
| NPI: | 1295387538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITCOMB | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | COMMANDING OFFICER 2D DENBN/NDC PSC 20310 | ||||||||
| Address2: | 315 MCGHUGH BLVD | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518479 | ||||||||
| Practice Location | |||||||||
| Address1: | COMMANDING OFFICER 2D DENBN/NDC PSC 20310 | ||||||||
| Address2: | 315 MCGHUGH BLVD | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2019 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901023177 | MI | Y | Dental Providers | Dentist |
No ID Information.