MEDICARE: DR. JACOB NAGELBLATT D.D.S.

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	1223G0001X	General Practice Dentistry	036780	NY

General Provider Information

NPI Number	:	1700987914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB NAGELBLATT D.D.S.

Provider Business Mailing Address
First Line	:	1540 EAST 21 ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-5036
Country	:	US
Telephone Number	:	718-851-0910
Fax Number	:	718-851-3897

Provider Business Practice Location Address
First Line	:	1524 56TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-4737
Country	:	US
Telephone Number	:	718-851-0910
Fax Number	:	718-851-3897

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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