Provider Demographics
NPI:1700534898
Name:JACOB WOOD DENTAL CORPORATION
Entity Type:Organization
Organization Name:JACOB WOOD DENTAL CORPORATION
Other - Org Name:GATEWAY DENTAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-540-9309
Mailing Address - Street 1:502 FIRST ST STE B
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-3764
Mailing Address - Country:US
Mailing Address - Phone:805-239-9597
Mailing Address - Fax:
Practice Address - Street 1:502 FIRST ST STE B
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-3764
Practice Address - Country:US
Practice Address - Phone:805-239-9597
Practice Address - Fax:805-239-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty