Provider Demographics
NPI:1346457819
Name:GRAPEVINE, JACOB LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:LYNN
Last Name:GRAPEVINE
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 1:1200 COIT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7756
Mailing Address - Country:US
Mailing Address - Phone:210-601-4980
Mailing Address - Fax:
Practice Address - Street 1:1200 COIT RD STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7756
Practice Address - Country:US
Practice Address - Phone:210-601-4980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice