Individual
STACY JACOB
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
15711 MADISON AVE STE 104, LAKEWOOD, OH 44107-5655
(216) 228-7950
(216) 228-7951
Mailing address
15711 MADISON AVE STE 104, LAKEWOOD, OH 44107-5655
(216) 228-7950
(216) 228-7951
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
30.026177
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
30.026177
DENTAL LICENCE
OH
Enumeration date
06/27/2020
Last updated
06/27/2020
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