Provider Demographics
NPI:1992175699
Name:ROBERT B JACOB, DDS, INC
Entity type:Organization
Organization Name:ROBERT B JACOB, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-268-1006
Mailing Address - Street 1:4617 RUFFNER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-2284
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB25912261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB25912-01Medicaid