MEDICARE: DR. ERIC S JACOB D.D.S.

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	048107	NY

General Provider Information

NPI Number	:	1932208881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC S JACOB D.D.S.

Provider Business Mailing Address
First Line	:	2495 NAVY PL
Second Line	:
City	:	BELLMORE
State	:	NY
Zip	:	11710-4812
Country	:	US
Telephone Number	:	516-679-6899
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 GLEN COVE RD
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-1726
Country	:	US
Telephone Number	:	516-621-1788
Fax Number	:

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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