Provider Demographics
NPI:1891041463
Name:ABY A JACOB, DMD, PC
Entity Type:Organization
Organization Name:ABY A JACOB, DMD, PC
Other - Org Name:PREMIER DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-939-6500
Mailing Address - Street 1:1012 W HEBRON PKWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-1122
Mailing Address - Country:US
Mailing Address - Phone:972-939-6500
Mailing Address - Fax:972-939-5300
Practice Address - Street 1:1012 W HEBRON PKWY
Practice Address - Street 2:SUITE 108
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-1122
Practice Address - Country:US
Practice Address - Phone:972-939-6500
Practice Address - Fax:972-939-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20704122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty