Healthcare Provider Details

I. General information

NPI: 1780804575
Provider Name (Legal Business Name): JUDITH JACOBS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 RICHARD DR
SHORT HILLS NJ
07078-1325
US

IV. Provider business mailing address

2 RICHARD DR
SHORT HILLS NJ
07078-1325
US

V. Phone/Fax

Practice location:
  • Phone: 973-376-3976
  • Fax:
Mailing address:
  • Phone: 973-376-3976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDI15578
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15778
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: