Provider Demographics
NPI:1669603411
Name:SOBOTA, JACQUELINE A (DMD, PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:A
Last Name:SOBOTA
Suffix:
Gender:F
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 MAMARONECK AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1900
Mailing Address - Country:US
Mailing Address - Phone:914-835-6004
Mailing Address - Fax:
Practice Address - Street 1:875 MAMARONECK AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-1900
Practice Address - Country:US
Practice Address - Phone:914-835-6004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055300-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03632684Medicaid