Provider Demographics
NPI:1366866683
Name:PEDIATRIC DENTISTRY ON PARK PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY ON PARK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:212-997-6453
Mailing Address - Street 1:949 PARK AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0315
Mailing Address - Country:US
Mailing Address - Phone:212-997-6453
Mailing Address - Fax:
Practice Address - Street 1:949 PARK AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0315
Practice Address - Country:US
Practice Address - Phone:212-997-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty