Healthcare Provider Details

I. General information

NPI: 1679250575
Provider Name (Legal Business Name): JACOB ANDREW PRUSSMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1857 PALOLO AVE
HONOLULU HI
96816-2925
US

IV. Provider business mailing address

1857 PALOLO AVE
HONOLULU HI
96816-2925
US

V. Phone/Fax

Practice location:
  • Phone: 516-673-8571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDT-3247
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: