Provider Demographics
NPI:1437520285
Name:JACOB DENT, DDS JUBAN CROSSING MODERN DENTISTRY A PROFESSIONAL CORPORA
Entity Type:Organization
Organization Name:JACOB DENT, DDS JUBAN CROSSING MODERN DENTISTRY A PROFESSIONAL CORPORA
Other - Org Name:JUBAN CROSSING MODERN DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:DENT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-788-1400
Mailing Address - Street 1:17000 RED HILL AVENUE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:10129 CROSSING WAY, STE 400
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726
Practice Address - Country:US
Practice Address - Phone:225-788-1400
Practice Address - Fax:225-667-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty