MEDICARE: LDFCB DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0004X	Dental Anesthesiology
2	1223G0001X	General Practice Dentistry
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
4	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
5	1223P0221X	Pediatric Dentistry	045485	NY

General Provider Information

NPI Number	:	1245334564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LDFCB DENTISTRY

Provider Business Mailing Address
First Line	:	29 N AIRMONT RD STE 22
Second Line	:
City	:	SUFFERN
State	:	NY
Zip	:	10901-4242
Country	:	US
Telephone Number	:	845-369-3703
Fax Number	:	945-369-3183

Provider Business Practice Location Address
First Line	:	3201 GRAND CONCOURSE
Second Line	:	SUITE 1E
City	:	BRONX
State	:	NY
Zip	:	10468-1247
Country	:	US
Telephone Number	:	718-367-7645
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BARRY L JACOBSON
Credential	:	DMD
Telephone Number	:	845-369-3703

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	07/12/2023

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Directions to “LDFCB DENTISTRY ” Practice Location

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