Provider Demographics
NPI:1053570200
Name:JACOB, STEVEN GARY (DMD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:GARY
Last Name:JACOB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 MAPLECREST RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1892
Mailing Address - Country:US
Mailing Address - Phone:260-485-5530
Mailing Address - Fax:260-485-8344
Practice Address - Street 1:7210 MAPLECREST RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-1892
Practice Address - Country:US
Practice Address - Phone:260-485-5530
Practice Address - Fax:260-485-8344
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010605A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist