Healthcare Provider Details

I. General information

NPI: 1730615329
Provider Name (Legal Business Name): MACK JACOB, DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 PRINCE ST
BERKELEY CA
94703-2519
US

IV. Provider business mailing address

2012 PRINCE ST
BERKELEY CA
94703-2519
US

V. Phone/Fax

Practice location:
  • Phone: 510-843-8568
  • Fax: 510-843-4448
Mailing address:
  • Phone: 510-843-8568
  • Fax: 510-843-4448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARILYN RODRIQUEZ
Title or Position: MANAGER
Credential:
Phone: 510-843-8568