Healthcare Provider Details

I. General information

NPI: 1073339024
Provider Name (Legal Business Name): ERIC JACOBS DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 SHALLOWFORD RD STE 146
MARIETTA GA
30066-2013
US

IV. Provider business mailing address

2421 SHALLOWFORD RD STE 146
MARIETTA GA
30066-2013
US

V. Phone/Fax

Practice location:
  • Phone: 770-926-6886
  • Fax:
Mailing address:
  • Phone: 770-926-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC JACOBS
Title or Position: DENTIST OWNER
Credential: DMD
Phone: 770-926-6886