Provider Demographics
NPI:1851775563
Name:JACOB, SUSANNA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSANNA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3360 ROUTE 343
Mailing Address - Street 2:
Mailing Address - City:AMENIA
Mailing Address - State:NY
Mailing Address - Zip Code:12501-5619
Mailing Address - Country:US
Mailing Address - Phone:845-838-7038
Mailing Address - Fax:
Practice Address - Street 1:3360 ROUTE 343
Practice Address - Street 2:
Practice Address - City:AMENIA
Practice Address - State:NY
Practice Address - Zip Code:12501-5619
Practice Address - Country:US
Practice Address - Phone:845-838-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058297-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist