Active NPI
Jacob Wiley-Blue Holtzclaw, DMD
- General Practice Dentistry
- Albany, GA
National Provider Identifier
1275150658
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- DN016080
- Practice address
- 1725 Dawson Rd
Albany, GA 31707-3362 - Phone
- (229) 883-7891
- NPI assigned
- Jul 1, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | DN016080 | GA | Primary |
Addresses
Primary practice location
1725 Dawson Rd
Albany, GA 31707-3362
Mailing address
315 Philema Rd Apt 15
Albany, GA 31701-1245
Phone (770) 815-0655
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DN016080 | GA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1593561600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1593561600000",
"number": "1275150658",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "315 PHILEMA RD APT 15",
"city": "ALBANY",
"state": "GA",
"postal_code": "317011245",
"telephone_number": "770-815-0655"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1725 DAWSON RD",
"city": "ALBANY",
"state": "GA",
"postal_code": "317073362",
"telephone_number": "229-883-7891"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HOLTZCLAW",
"first_name": "JACOB",
"middle_name": "WILEY-BLUE",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-07-01",
"last_updated": "2020-07-01",
"certification_date": "2020-07-01",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "GA",
"license": "DN016080",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Albany, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.