Provider Demographics
NPI:1235385055
Name:JOHN, JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:JOHN
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 1:701 BLOODGOOD CT
Mailing Address - Street 2:
Mailing Address - City:CENTRAL VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10917-3626
Mailing Address - Country:US
Mailing Address - Phone:917-742-3081
Mailing Address - Fax:
Practice Address - Street 1:37 TRIANGLE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-3371
Practice Address - Country:US
Practice Address - Phone:845-292-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY054091OtherNEW YORK STATE DENTAL LICENSE