Provider Demographics
NPI:1427207588
Name:JACOB, STANLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
Last Name:JACOB
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 1:201 KYLES WAY
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6621
Mailing Address - Country:US
Mailing Address - Phone:516-476-5450
Mailing Address - Fax:
Practice Address - Street 1:69 NUGENT ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1959
Practice Address - Country:US
Practice Address - Phone:516-476-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-14
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0100181223G0001X
NY541011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice