Provider Demographics
NPI:1669032603
Name:JACAS, JOSE CARLOS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:CARLOS
Last Name:JACAS
Suffix:
Gender:M
Credentials:DMD
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 82969
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-2969
Mailing Address - Country:US
Mailing Address - Phone:813-866-0930
Mailing Address - Fax:813-405-3722
Practice Address - Street 1:8108 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-3103
Practice Address - Country:US
Practice Address - Phone:813-866-0930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24211122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist