Healthcare Provider Details

I. General information

NPI: 1003517640
Provider Name (Legal Business Name): JACOB FARES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1391 COMMERCIAL WAY
SPRING HILL FL
34606-4521
US

IV. Provider business mailing address

12948 SERONERA VALLEY CT
SPRING HILL FL
34610-7667
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-4977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10000437
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN31445
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: