MEDICARE: DR. MARINET F JACOB D.M.D.

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	1223G0001X	General Practice Dentistry	22DI02439500	NJ

General Provider Information

NPI Number	:	1295038636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARINET F JACOB D.M.D.

Provider Business Mailing Address
First Line	:	23 W PROSPECT ST
Second Line	:
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-2116
Country	:	US
Telephone Number	:	732-651-6262
Fax Number	:	732-651-6070

Provider Business Practice Location Address
First Line	:	23 W PROSPECT ST
Second Line	:
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-2116
Country	:	US
Telephone Number	:	732-651-6262
Fax Number	:	732-651-6070

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

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	12/07/2010

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