Provider Demographics
NPI:1518089432
Name:JACOB, ABY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:ABY
Middle Name:A
Last Name:JACOB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:ABY
Other - Middle Name:A
Other - Last Name:JACOB CHACKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1012 W HEBRON PKWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-1122
Mailing Address - Country:US
Mailing Address - Phone:972-939-6500
Mailing Address - Fax:972-939-5300
Practice Address - Street 1:6504 HIGHWAY 78
Practice Address - Street 2:SUITE 146
Practice Address - City:SACHSE
Practice Address - State:TX
Practice Address - Zip Code:75048-3259
Practice Address - Country:US
Practice Address - Phone:972-530-3644
Practice Address - Fax:972-530-3655
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist