Provider Demographics
NPI:1164688115
Name:JACOBS, BENJAMIN HARRISON (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:HARRISON
Last Name:JACOBS
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 1:10 AMSTERDAM AVE
Mailing Address - Street 2:APT 406
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-7464
Mailing Address - Country:US
Mailing Address - Phone:908-591-9646
Mailing Address - Fax:
Practice Address - Street 1:10 AMSTERDAM AVE
Practice Address - Street 2:APT 406
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7464
Practice Address - Country:US
Practice Address - Phone:908-591-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053451-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery