Provider Demographics
NPI:1992158950
Name:BISHOP, JACOB RYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RYAN
Last Name:BISHOP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13301 SHELBYVILLE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3937
Mailing Address - Country:US
Mailing Address - Phone:502-599-8996
Mailing Address - Fax:
Practice Address - Street 1:13301 SHELBYVILLE RD STE 105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3937
Practice Address - Country:US
Practice Address - Phone:502-631-9627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9778122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist