Provider Demographics
NPI:1902476682
Name:GROOM, JACOB (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GROOM
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 NW WALDEN ST
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-9130
Mailing Address - Country:US
Mailing Address - Phone:503-702-6532
Mailing Address - Fax:
Practice Address - Street 1:7012 NE 40TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3052
Practice Address - Country:US
Practice Address - Phone:360-254-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE612030361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty