Provider Demographics
NPI:1063856912
Name:SMITH, JACOB OLIVER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:OLIVER
Last Name:SMITH
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 1:609 SE HENDRIX ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4166
Mailing Address - Country:US
Mailing Address - Phone:573-380-8867
Mailing Address - Fax:
Practice Address - Street 1:4307 S PLEASANT CROSSING BLVD STE 103
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1347
Practice Address - Country:US
Practice Address - Phone:479-553-9215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120194051223G0001X
AR44121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice