=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073339024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIC JACOBS DMD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2421 SHALLOWFORD RD STE 146
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30066-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-926-6886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2421 SHALLOWFORD RD STE 146
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30066-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-926-6886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST OWNER
-----------------------------------------------------
Name | DR. ERIC JACOBS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 770-926-6886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------