Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 22DI02252800 | NJ |
N | 204E00000X | Oral & Maxillofacial Surgeon | 054217-1 | NY |
NPI | 1164540233 |
---|---|
Provider Name | Dr. Gregg Andrew Jacob |
First Address | Florham Park, NJ 07932-1508 |
Second Address | Florham Park, NJ 07932-1508 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2007 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
91001810700 | (05) | NJ |
V03911 | (02) | NJ |