Provider Demographics
NPI:1033358593
Name:JACOB, EVELINDA D (DDS)
Entity Type:Individual
Prefix:
First Name:EVELINDA
Middle Name:D
Last Name:JACOB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100 MANDARIN COURT
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344
Mailing Address - Country:US
Mailing Address - Phone:818-832-7002
Mailing Address - Fax:
Practice Address - Street 1:17100 MANDARIN CT
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-2308
Practice Address - Country:US
Practice Address - Phone:818-832-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56122122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist