Provider Demographics
NPI:1265858542
Name:ESAGOFF, JACOB F (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:F
Last Name:ESAGOFF
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:P.O. BOX 6668
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-6664
Mailing Address - Country:US
Mailing Address - Phone:310-858-1234
Mailing Address - Fax:310-858-7776
Practice Address - Street 1:9301 WILSHIRE BLVD.
Practice Address - Street 2:#409
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-6668
Practice Address - Country:US
Practice Address - Phone:310-858-1234
Practice Address - Fax:310-858-7776
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist