Provider Demographics
NPI:1699541813
Name:JACOB BROTZMAN DMD PLLC
Entity type:Organization
Organization Name:JACOB BROTZMAN DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BROTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:919-961-8552
Mailing Address - Street 1:14 E DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-3033
Mailing Address - Country:US
Mailing Address - Phone:919-961-8552
Mailing Address - Fax:
Practice Address - Street 1:4721 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3521
Practice Address - Country:US
Practice Address - Phone:919-961-8552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental