Healthcare Provider Details

I. General information

NPI: 1831618529
Provider Name (Legal Business Name): NORTHEAST FACIAL AND ORAL SURGERY SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 07/21/2022
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

VIII. Authorized Official

Name: DR. GREGG A JACOB
Title or Position: OWNER
Credential: DMD
Phone: 973-360-1100