Provider Demographics
NPI:1922080654
Name:JACOBSON, ANDREW GENE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GENE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:14 VALLEY LN W
Mailing Address - Street 2:
Mailing Address - City:N WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3633
Mailing Address - Country:US
Mailing Address - Phone:516-791-1278
Mailing Address - Fax:516-792-0196
Practice Address - Street 1:6419 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-6237
Practice Address - Country:US
Practice Address - Phone:718-456-8131
Practice Address - Fax:516-791-3161
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2015-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0341971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113185578Medicare UPIN