Provider Demographics
NPI:1558405241
Name:JACOB, JOLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOLY
Middle Name:
Last Name:JACOB
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 1:443 W GIRARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-1454
Mailing Address - Country:US
Mailing Address - Phone:215-763-7985
Mailing Address - Fax:215-763-7987
Practice Address - Street 1:443 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-1454
Practice Address - Country:US
Practice Address - Phone:215-763-7985
Practice Address - Fax:215-763-7987
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030002L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0164167305Medicaid