Provider Demographics
NPI:1114183837
Name:WALLACH, JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:WALLACH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-2627
Mailing Address - Country:US
Mailing Address - Phone:845-358-1728
Mailing Address - Fax:
Practice Address - Street 1:99 N BROADWAY
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2627
Practice Address - Country:US
Practice Address - Phone:845-358-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50 053926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist