Provider Demographics
NPI:1144313271
Name:JACOBSON, MARK NATHAN (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:NATHAN
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E 43RD ST
Mailing Address - Street 2:#1304
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-4707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 E 43RD ST
Practice Address - Street 2:#1304
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-4707
Practice Address - Country:US
Practice Address - Phone:212-697-3946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0361391223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics