Provider Demographics
NPI:1477320703
Name:LEGACY SMILES OF SAN JUAN PLLC
Entity Type:Organization
Organization Name:LEGACY SMILES OF SAN JUAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-574-4666
Mailing Address - Street 1:826 W US HIGHWAY 83 STE B
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-2141
Mailing Address - Country:US
Mailing Address - Phone:956-475-3005
Mailing Address - Fax:956-475-3011
Practice Address - Street 1:826 W US HIGHWAY 83 STE B
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-2141
Practice Address - Country:US
Practice Address - Phone:956-475-3005
Practice Address - Fax:956-475-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty