Healthcare Provider Details

I. General information

NPI: 1508124074
Provider Name (Legal Business Name): PABLO JACOBO DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 W ROBINHOOD DR SUITE 200
STOCKTON CA
95207-5621
US

IV. Provider business mailing address

1035 W ROBINHOOD DR SUITE 200
STOCKTON CA
95207-5621
US

V. Phone/Fax

Practice location:
  • Phone: 209-952-3687
  • Fax: 209-952-6267
Mailing address:
  • Phone: 209-952-3687
  • Fax: 209-952-6267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number61240
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number100679
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38433
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60929
License Number StateCA

VIII. Authorized Official

Name: MR. CARLOS JACOBO
Title or Position: MANAGER
Credential:
Phone: 209-952-3687