MEDICARE: JACOBS AND THATCHER DENTISTRY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1407244189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACOBS AND THATCHER DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	1601 RICKENBACKER DR
Second Line	:	SUITE #7
City	:	SUN CITY CENTER
State	:	FL
Zip	:	33573-5332
Country	:	US
Telephone Number	:	813-634-1932
Fax Number	:	813-634-8612

Provider Business Practice Location Address
First Line	:	1601 RICKENBACKER DR
Second Line	:	SUITE #7
City	:	SUN CITY CENTER
State	:	FL
Zip	:	33573-5332
Country	:	US
Telephone Number	:	813-634-1932
Fax Number	:	813-634-8612

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. BRYAN R. THATCHER
Credential	:	D.M.D.
Telephone Number	:	813-634-1932

Provider Enumeration Date	:	01/02/2015
Last Update Date	:	01/02/2015

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