Provider Demographics
NPI:1326303272
Name:KIRBY, JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KIRBY
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 1:5804 NEW COPELAND RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-6217
Mailing Address - Country:US
Mailing Address - Phone:903-561-1610
Mailing Address - Fax:
Practice Address - Street 1:5804 NEW COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6217
Practice Address - Country:US
Practice Address - Phone:903-561-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist