Provider Demographics
NPI:1477937183
Name:JACOB, TESSIE (DDS)
Entity type:Individual
Prefix:DR
First Name:TESSIE
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 WEST STREET
Mailing Address - Street 2:BUILDING#1 SUITE#5
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-6006
Mailing Address - Country:US
Mailing Address - Phone:860-414-6897
Mailing Address - Fax:
Practice Address - Street 1:1131 WEST STREET
Practice Address - Street 2:BUILDING#1 SUITE#5
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-6006
Practice Address - Country:US
Practice Address - Phone:860-414-6897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11465122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist