Provider Demographics
NPI:1295806883
Name:ORBACH, JACOB E (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:E
Last Name:ORBACH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15010 71ST AVE
Mailing Address - Street 2:APT. 4C
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2143
Mailing Address - Country:US
Mailing Address - Phone:718-520-8014
Mailing Address - Fax:
Practice Address - Street 1:3973 61ST ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3554
Practice Address - Country:US
Practice Address - Phone:718-429-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0515031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02567297Medicaid