MEDICARE: LASER DENTISTRY FOR CHILDREN LLC

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
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
4	1223D0004X	Dental Anesthesiology
5	1223P0221X	Pediatric Dentistry	045485	NY

General Provider Information

NPI Number	:	1871604371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LASER DENTISTRY FOR CHILDREN LLC

Provider Business Mailing Address
First Line	:	13514 JEWEL AVE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11367-1920
Country	:	US
Telephone Number	:	718-997-6453
Fax Number	:

Provider Business Practice Location Address
First Line	:	13514 JEWEL AVE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11367-1920
Country	:	US
Telephone Number	:	718-997-6453
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/12/2023

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