Provider Demographics
NPI:1215093315
Name:JACOB, ROBERT B (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:JACOB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 RUFFNER ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-2285
Mailing Address - Country:US
Mailing Address - Phone:858-268-1006
Mailing Address - Fax:858-268-5097
Practice Address - Street 1:4617 RUFFNER ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2284
Practice Address - Country:US
Practice Address - Phone:858-268-1006
Practice Address - Fax:858-268-5097
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB 259121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB25912-01Medicaid
CA25912OtherSTATE DENTAL LICENSE