Provider Demographics
NPI:1508124074
Name:PABLO JACOBO DDS, INC
Entity Type:Organization
Organization Name:PABLO JACOBO DDS, INC
Other - Org Name:GOTTA SMILE DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-952-3687
Mailing Address - Street 1:1035 W ROBINHOOD DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5621
Mailing Address - Country:US
Mailing Address - Phone:209-952-3687
Mailing Address - Fax:209-952-6267
Practice Address - Street 1:1035 W ROBINHOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5621
Practice Address - Country:US
Practice Address - Phone:209-952-3687
Practice Address - Fax:209-952-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61240122300000X
CA100679122300000X
CA384331223G0001X
CA609291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38433OtherCA DENTAL STATE BOARD
CA61240OtherCA DENTAL BOARD
CA60929OtherCA DENTAL STATE BOARD
CA100679OtherCA DENTAL BOARD