Provider Demographics
NPI:1619012218
Name:JACOBS, RICHARD A (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:JACOBS
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 1:1423 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4411
Mailing Address - Country:US
Mailing Address - Phone:203-562-0234
Mailing Address - Fax:203-865-2556
Practice Address - Street 1:1423 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4411
Practice Address - Country:US
Practice Address - Phone:203-562-0234
Practice Address - Fax:203-865-2556
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice