Provider Demographics
NPI:1689893463
Name:JACOBS, THOMAS GREGORY (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GREGORY
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:T
Other - Middle Name:GREGORY
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1601 RICKENBACKER DR
Mailing Address - Street 2:SUITE #7
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573
Mailing Address - Country:US
Mailing Address - Phone:813-634-1932
Mailing Address - Fax:813-634-8612
Practice Address - Street 1:1601 RICKENBACKER DR
Practice Address - Street 2:SUITE #7
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573
Practice Address - Country:US
Practice Address - Phone:813-634-1932
Practice Address - Fax:813-634-8612
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103131223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice