Healthcare Provider Details

I. General information

NPI: 1164540233
Provider Name (Legal Business Name): GREGG ANDREW JACOB D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 HANOVER RD STE 240
FLORHAM PARK NJ
07932-1508
US

IV. Provider business mailing address

83 HANOVER RD STE 240
FLORHAM PARK NJ
07932-1508
US

V. Phone/Fax

Practice location:
  • Phone: 973-360-1100
  • Fax: 973-360-1101
Mailing address:
  • Phone: 973-360-1100
  • Fax: 973-360-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02252800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number054217-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: