Provider Demographics
NPI:1790495760
Name:JACOB, AUSTIN JOLY (DMD)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JOLY
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 1:123 S PAVILION AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-3611
Mailing Address - Country:US
Mailing Address - Phone:856-393-8510
Mailing Address - Fax:
Practice Address - Street 1:123 S PAVILION AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:NJ
Practice Address - Zip Code:08075-3611
Practice Address - Country:US
Practice Address - Phone:856-393-8510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02940800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty