Provider Demographics
NPI:1134675770
Name:ABBOTT, JACOB CLIFFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CLIFFORD
Last Name:ABBOTT
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 1:8461 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179
Mailing Address - Country:US
Mailing Address - Phone:817-236-8771
Mailing Address - Fax:
Practice Address - Street 1:8461 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179
Practice Address - Country:US
Practice Address - Phone:817-236-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice