Healthcare Provider Details

I. General information

NPI: 1235385055
Provider Name (Legal Business Name): JACOB JOHN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 ROUTE 59 STE A1
SUFFERN NY
10901-5013
US

IV. Provider business mailing address

9 DUNMORE RD
NEW CITY NY
10956-4407
US

V. Phone/Fax

Practice location:
  • Phone: 845-356-8844
  • Fax: 845-547-2218
Mailing address:
  • Phone: 917-742-3081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number054091
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: