Provider Demographics
NPI:1982287892
Name:ROPER, JACOB (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:ROPER
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 1:1242 NW SALISBURY DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-6349
Mailing Address - Country:US
Mailing Address - Phone:801-946-0105
Mailing Address - Fax:
Practice Address - Street 1:1825 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1043
Practice Address - Country:US
Practice Address - Phone:541-479-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT214931223G0001X
ORD117881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice