Provider Demographics
NPI:1538279625
Name:JACOBSON, BARRY L (DMD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:29 N AIRMONT RD STE 22
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4242
Mailing Address - Country:US
Mailing Address - Phone:845-369-3703
Mailing Address - Fax:845-369-3183
Practice Address - Street 1:135-14 JEWEL AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367
Practice Address - Country:US
Practice Address - Phone:718-997-6453
Practice Address - Fax:718-793-8956
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0454851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01649187Medicaid