Provider Demographics
NPI:1710611959
Name:SMITH, JACOB GANT (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:GANT
Last Name:SMITH
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 1:502 SE 31ST TER
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2817
Mailing Address - Country:US
Mailing Address - Phone:352-789-3696
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744-8200
Practice Address - Country:US
Practice Address - Phone:727-398-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL272141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice