Provider Demographics
NPI:1003548405
Name:BURCH, JACOB KEITH (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:KEITH
Last Name:BURCH
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 1:2004 CHARITY LN
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7972
Mailing Address - Country:US
Mailing Address - Phone:252-676-5500
Mailing Address - Fax:
Practice Address - Street 1:801 PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-2143
Practice Address - Country:US
Practice Address - Phone:252-371-0117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC128431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice