Provider Demographics
NPI:1164540233
Name:JACOB, GREGG ANDREW (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ANDREW
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 1:83 HANOVER RD STE 240
Mailing Address - Street 2:
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1508
Mailing Address - Country:US
Mailing Address - Phone:973-360-1100
Mailing Address - Fax:973-360-1101
Practice Address - Street 1:83 HANOVER RD STE 240
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1508
Practice Address - Country:US
Practice Address - Phone:973-360-1100
Practice Address - Fax:973-360-1101
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022528001223S0112X
NY054217-1204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ91001810700Medicaid
NJV03911Medicare UPIN
NJ088193TVTMedicare ID - Type UnspecifiedMEDICARE ID NUMBER