Provider Demographics
NPI:1578778577
Name:JACOBS, DIANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:JACOBS
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 1:1098 SHELL BLVD # A
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-2902
Mailing Address - Country:US
Mailing Address - Phone:650-634-1318
Mailing Address - Fax:650-341-3472
Practice Address - Street 1:1098 SHELL BLVD # A
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-2902
Practice Address - Country:US
Practice Address - Phone:650-634-1318
Practice Address - Fax:650-341-3472
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA433491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice