Provider Demographics
NPI:1114143120
Name:T GREGORY JACOBS DDS PA
Entity Type:Organization
Organization Name:T GREGORY JACOBS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:T
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-310-9580
Mailing Address - Street 1:4208 W BAY TO BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6608
Mailing Address - Country:US
Mailing Address - Phone:813-657-3000
Mailing Address - Fax:
Practice Address - Street 1:4208 W BAY TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6608
Practice Address - Country:US
Practice Address - Phone:813-657-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty