Healthcare Provider Details

I. General information

NPI: 1245334564
Provider Name (Legal Business Name): LDFCB DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 GRAND CONCOURSE SUITE 1E
BRONX NY
10468-1247
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 718-367-7645
  • Fax:
Mailing address:
  • Phone: 845-369-3703
  • Fax: 945-369-3183

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 Number045485
License Number StateNY

VIII. Authorized Official

Name: BARRY L JACOBSON
Title or Position: OWNER
Credential: DMD
Phone: 845-369-3703