Healthcare Provider Details

I. General information

NPI: 1922848522
Provider Name (Legal Business Name): IAN JACOB GEORGE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 E MAIN ST
MOUNT KISCO NY
10549-3435
US

IV. Provider business mailing address

2421 42ND ST
ASTORIA NY
11103-2803
US

V. Phone/Fax

Practice location:
  • Phone: 914-244-3900
  • Fax:
Mailing address:
  • Phone: 614-352-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: