MEDICARE: AMARILIS JACOBO DENTAL OFFICE PC

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	0455771	NY

General Provider Information

NPI Number	:	1326299181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMARILIS JACOBO DENTAL OFFICE PC

Provider Business Mailing Address
First Line	:	131 W 110TH ST
Second Line	:	SUITE 1D
City	:	NEW YORK
State	:	NY
Zip	:	10026-4202
Country	:	US
Telephone Number	:	212-678-1944
Fax Number	:	212-666-6857

Provider Business Practice Location Address
First Line	:	131 W 110TH ST
Second Line	:	SUITE 1D
City	:	NEW YORK
State	:	NY
Zip	:	10026-4202
Country	:	US
Telephone Number	:	212-678-1944
Fax Number	:	212-666-6857

Authorized Official
Title or Position	:	DENTIST
Name	:	AMARILIS JACOBO
Credential	:	DDS
Telephone Number	:	212-678-1944

Provider Enumeration Date	:	10/09/2008
Last Update Date	:	07/07/2021

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