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General NPI Number Information
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NPI Number | 1881936441
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY OF ALBANY, PLLC
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Dates
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Enumeration Date | 03/21/2013
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Last Update Date | 07/11/2023
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Provider Practice Location Address
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Address Line | 980 WESTERN AVE
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City | ALBANY
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State | NY
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Zip | 12203-2799
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Country | US
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Telephone | 518-512-3072
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Fax | 518-621-7286
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Provider Business Mailing Address
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Address Line | 29 N AIRMONT RD STE 22
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City | SUFFERN
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State | NY
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Zip | 10901-4242
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Country | US
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Telephone | 845-369-3703
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Fax | 845-369-3183
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Authorized Official
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Title or Position | CEO
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Name | DR. BARRY L JACOBSON
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Credential | DMD
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Telephone | 845-369-3703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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Taxonomy #4
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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Taxonomy #5
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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