Provider Demographics
NPI:1548385131
Name:JACOBS, JOHANNA M (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:M
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W END AVE
Mailing Address - Street 2:8H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5760
Mailing Address - Country:US
Mailing Address - Phone:212-496-0136
Mailing Address - Fax:
Practice Address - Street 1:127 W 79TH ST
Practice Address - Street 2:MANHATTAN DENTAL CARE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6416
Practice Address - Country:US
Practice Address - Phone:212-580-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist