Provider Demographics
NPI:1700987674
Name:REVERCOMB, JACOB L (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:L
Last Name:REVERCOMB
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 1:8076 CAZENOVIA RD
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104
Mailing Address - Country:US
Mailing Address - Phone:315-682-8400
Mailing Address - Fax:315-682-2602
Practice Address - Street 1:8076 CAZENOVIA RD
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104
Practice Address - Country:US
Practice Address - Phone:315-682-8400
Practice Address - Fax:315-682-2602
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0488331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice