Provider Demographics
NPI:1932853207
Name:GRACA, JACOB ANTONIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ANTONIO
Last Name:GRACA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 BEEBE RD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NY
Mailing Address - Zip Code:14172-9648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5363 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-333-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109539122300000X
NY063865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist