Healthcare Provider Details

I. General information

NPI: 1942202163
Provider Name (Legal Business Name): JEROME TABACCA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 BETHEL RD
COLUMBUS OH
43220-1810
US

IV. Provider business mailing address

1707 BETHEL RD
COLUMBUS OH
43220-1810
US

V. Phone/Fax

Practice location:
  • Phone: 614-459-0050
  • Fax: 614-459-1955
Mailing address:
  • Phone: 614-459-0050
  • Fax: 614-459-1955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberOH14335
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: