Provider Demographics
NPI:1124507421
Name:JACOB, TRACEY LEIGH (RDH)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LEIGH
Last Name:JACOB
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3400
Mailing Address - Country:US
Mailing Address - Phone:586-489-9868
Mailing Address - Fax:
Practice Address - Street 1:2850 BERKSHIRE DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3400
Practice Address - Country:US
Practice Address - Phone:586-489-9868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012495124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist