Provider Demographics
NPI:1932447620
Name:JACOB, TINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TINA
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 1:5 PINE WEST PLZ STE 504
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-5587
Mailing Address - Country:US
Mailing Address - Phone:518-456-5134
Mailing Address - Fax:
Practice Address - Street 1:5 PINE WEST PLZ STE 504
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5587
Practice Address - Country:US
Practice Address - Phone:518-456-5134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0567921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice