Provider Demographics
NPI:1124282207
Name:CRAGUN, JACOB DAVID (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DAVID
Last Name:CRAGUN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:JAKE
Other - Middle Name:DAVID
Other - Last Name:CRAGUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:5858 W. MAIN ST.
Mailing Address - Street 2:SUITE 290
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034
Mailing Address - Country:US
Mailing Address - Phone:310-902-7822
Mailing Address - Fax:
Practice Address - Street 1:5858 W. MAIN ST.
Practice Address - Street 2:SUITE 290
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034
Practice Address - Country:US
Practice Address - Phone:310-902-7822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6791223E0200X
TX252381223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics