Provider Demographics
NPI:1467989921
Name:DORFMAN, JAKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:DORFMAN
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 1:3076 SCHOENERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-2210
Mailing Address - Country:US
Mailing Address - Phone:610-865-2777
Mailing Address - Fax:
Practice Address - Street 1:3076 SCHOENERSVILLE RD
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-2210
Practice Address - Country:US
Practice Address - Phone:610-865-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040396122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1356591903OtherSPARK ORTHODONTICS, P.C.