Healthcare Provider Details

I. General information

NPI: 1700534898
Provider Name (Legal Business Name): JACOB WOOD DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/20/2022
Certification Date: 03/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 FIRST ST STE B
PASO ROBLES CA
93446-3764
US

IV. Provider business mailing address

502 FIRST ST STE B
PASO ROBLES CA
93446-3764
US

V. Phone/Fax

Practice location:
  • Phone: 805-239-9597
  • Fax: 805-239-4142
Mailing address:
  • Phone: 805-239-9597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACOB ALAN WOOD
Title or Position: OWNER, CEO
Credential: DDS
Phone: 805-540-9309