MEDICARE: JACOB POURAT DDS MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	22DI02914400	NJ

General Provider Information

NPI Number	:	1093447732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB POURAT DDS MS

Provider Business Mailing Address
First Line	:	194 HARWOOD PL
Second Line	:
City	:	PARAMUS
State	:	NJ
Zip	:	07652-4606
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1137 PALISADE AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6427
Country	:	US
Telephone Number	:	201-224-8180
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2022
Last Update Date	:	06/30/2022

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