Provider Demographics
NPI:1578010245
Name:NATHANIEL JACOB DDS PLLC
Entity type:Organization
Organization Name:NATHANIEL JACOB DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-640-6892
Mailing Address - Street 1:100 WASHINGTON ST
Mailing Address - Street 2:SUITE LB1
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-3147
Mailing Address - Country:US
Mailing Address - Phone:516-483-8383
Mailing Address - Fax:516-483-1116
Practice Address - Street 1:100 WASHINGTON ST
Practice Address - Street 2:SUITE LB1
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-3147
Practice Address - Country:US
Practice Address - Phone:516-483-8383
Practice Address - Fax:516-483-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty