Provider Demographics
NPI:1811226715
Name:JACOB, NEVILLE KALLARACKEL (BDS,DDS)
Entity Type:Individual
Prefix:DR
First Name:NEVILLE
Middle Name:KALLARACKEL
Last Name:JACOB
Suffix:
Gender:M
Credentials:BDS,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7517 CELEBRATION WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014
Mailing Address - Country:US
Mailing Address - Phone:317-702-0660
Mailing Address - Fax:
Practice Address - Street 1:4420 DIXIE HWY STE 110
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2986
Practice Address - Country:US
Practice Address - Phone:502-447-3323
Practice Address - Fax:913-752-9116
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY98591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice