Provider Demographics
NPI:1669083895
Name:JACOB, GEORGE JERYN (BDS, MDS, MS)
Entity type:Individual
Prefix:
First Name:GEORGE JERYN
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:BDS, MDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15922 ELDORADO PKWY STE 500-1756
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-5836
Mailing Address - Country:US
Mailing Address - Phone:214-729-0426
Mailing Address - Fax:
Practice Address - Street 1:1180 N PRESTON RD STE 20
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-9291
Practice Address - Country:US
Practice Address - Phone:972-426-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX364751223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics