Provider Demographics
NPI:1770640997
Name:JACOBS, SHERIDA DAWN (DMD)
Entity Type:Individual
Prefix:
First Name:SHERIDA
Middle Name:DAWN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 ARKWRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1707
Mailing Address - Country:US
Mailing Address - Phone:478-405-7797
Mailing Address - Fax:
Practice Address - Street 1:4132 ARKWRIGHT RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1707
Practice Address - Country:US
Practice Address - Phone:478-405-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0116961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA39416OtherAVESIS VENDOR #
GA168140OtherDORAL PAYEE #