Provider Demographics
NPI:1619079704
Name:KING OF PRUSSIA DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:KING OF PRUSSIA DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-265-4142
Mailing Address - Street 1:491 ALLENDALE RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1426
Mailing Address - Country:US
Mailing Address - Phone:610-265-4142
Mailing Address - Fax:610-265-0926
Practice Address - Street 1:491 ALLENDALE RD
Practice Address - Street 2:SUITE 306
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1432
Practice Address - Country:US
Practice Address - Phone:610-265-4142
Practice Address - Fax:610-265-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA06-00000016531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty