Provider Demographics
NPI:1215255005
Name:JACOB, ALAN TODD (DMD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:TODD
Last Name:JACOB
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-2688
Mailing Address - Country:US
Mailing Address - Phone:973-759-1010
Mailing Address - Fax:973-759-2411
Practice Address - Street 1:484 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-2688
Practice Address - Country:US
Practice Address - Phone:973-759-1010
Practice Address - Fax:973-759-2411
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ222771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice