Jacob Mack, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DEN.00205341 Issued in CO

Practice address

4175 S Alamo Ave
Davis Monthan Afb, AZ 85707-4402

Phone

(719) 333-5192

NPI assigned

Aug 10, 2022

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1660089600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1753315200000",
    "number": "1003544842",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4175 S ALAMO AVE",
            "city": "DAVIS MONTHAN AFB",
            "state": "AZ",
            "postal_code": "857074402"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4175 S ALAMO AVE",
            "city": "DAVIS MONTHAN AFB",
            "state": "AZ",
            "postal_code": "857074402",
            "telephone_number": "719-333-5192"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MACK",
        "first_name": "JACOB",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-08-10",
        "last_updated": "2025-07-24",
        "certification_date": "2025-07-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CO",
            "license": "66362065",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CO",
            "license": "DEN.00205341",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sandra Kay Kuhn, WHNP
• Matthew Robert Land, PA
• Daniel Cooper Lee Jr., DDS
• Robin L Livingston, DMD
• Payton Lofton, DMD
• Annetta Rachelle Medaugh, R.N.
• Shane Michael Mikolajewski, PA-C
• Nicholas Miller, DDS
• Erin Moore, PA-C
• John Patrick Moran, M.D.

• General Practice Dentistry in Davis Monthan Afb, AZ
• Providers in Davis Monthan Afb, AZ by specialty
• General Practice Dentistry in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.