Healthcare Provider Details

I. General information

NPI: 1619649092
Provider Name (Legal Business Name): JACOB TUCKER BARTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27701 SCOTT RD STE 107
MENIFEE CA
92584-9434
US

IV. Provider business mailing address

27701 SCOTT RD STE 107
MENIFEE CA
92584-9434
US

V. Phone/Fax

Practice location:
  • Phone: 951-301-6100
  • Fax:
Mailing address:
  • Phone: 951-301-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number106652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: