Healthcare Provider Details

I. General information

NPI: 1881936441
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF ALBANY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 WESTERN AVE
ALBANY NY
12203-2799
US

IV. Provider business mailing address

29 N AIRMONT RD STE 22
SUFFERN NY
10901-4242
US

V. Phone/Fax

Practice location:
  • Phone: 518-512-3072
  • Fax: 518-621-7286
Mailing address:
  • Phone: 845-369-3703
  • Fax: 845-369-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. BARRY L JACOBSON
Title or Position: CEO
Credential: DMD
Phone: 845-369-3703