Healthcare Provider Details

I. General information

NPI: 1366866683
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY ON PARK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 PARK AVE 1ST FLOOR
NEW YORK NY
10028-0315
US

IV. Provider business mailing address

949 PARK AVE 1ST FLOOR
NEW YORK NY
10028-0315
US

V. Phone/Fax

Practice location:
  • Phone: 212-997-6453
  • Fax:
Mailing address:
  • Phone: 212-997-6453
  • Fax:

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: OWNER
Credential: DMD
Phone: 212-997-6453