Provider Demographics
NPI:1508094608
Name:JACOB, TERESA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
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:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-0312
Mailing Address - Country:US
Mailing Address - Phone:401-567-0800
Mailing Address - Fax:401-567-0900
Practice Address - Street 1:308 CALLAHAN RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-7739
Practice Address - Country:US
Practice Address - Phone:401-295-9706
Practice Address - Fax:401-295-0920
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILD000461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice