Provider Demographics
NPI:1699897009
Name:JERROLD T. JACOB D.M.D., P.A.
Entity type:Organization
Organization Name:JERROLD T. JACOB D.M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:TED
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-759-1010
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty