Provider Demographics
NPI:1336509256
Name:JACOBS, CARLY (DMD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1149 W LANCASTER AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2722
Mailing Address - Country:US
Mailing Address - Phone:610-851-4299
Mailing Address - Fax:
Practice Address - Street 1:1149 W LANCASTER AVE STE 5
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2722
Practice Address - Country:US
Practice Address - Phone:610-851-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty