Healthcare Provider Details

I. General information

NPI: 1215753348
Provider Name (Legal Business Name): JACOB KIRIAKOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 CHESTER AVE
CLEVELAND OH
44106-1666
US

IV. Provider business mailing address

10555 EUCLID AVE
CLEVELAND OH
44106-2207
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-3200
  • Fax:
Mailing address:
  • Phone: 925-895-1543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberRES.005144
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: