Healthcare Provider Details

I. General information

NPI: 1518608918
Provider Name (Legal Business Name): JACOB LYSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 S TOLLGATE RD STE 212
BEL AIR MD
21015-5902
US

IV. Provider business mailing address

151 WESTCHESTER HALL
STONY BROOK NY
11794-8711
US

V. Phone/Fax

Practice location:
  • Phone: 443-996-6691
  • Fax:
Mailing address:
  • Phone: 631-444-2557
  • Fax: 631-444-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number063929
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number18381
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: