Healthcare Provider Details

I. General information

NPI: 1508094608
Provider Name (Legal Business Name): TERESA JACOB D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CALLAHAN RD
NORTH KINGSTOWN RI
02852-7739
US

IV. Provider business mailing address

PO BOX 312
PASCOAG RI
02859-0312
US

V. Phone/Fax

Practice location:
  • Phone: 401-295-9706
  • Fax: 401-295-0920
Mailing address:
  • Phone: 401-567-0800
  • Fax: 401-567-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberLD00046
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: