Provider Demographics
NPI:1801406129
Name:PERRY, JACOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:PERRY
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 1:10 RIVERWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5017
Mailing Address - Country:US
Mailing Address - Phone:801-319-3219
Mailing Address - Fax:
Practice Address - Street 1:10 RIVERWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5017
Practice Address - Country:US
Practice Address - Phone:801-319-3219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-01
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist