Active NPI
Mary Jacob, DMD
- General Practice Dentistry
- Revere, MA
National Provider Identifier
1124537667
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- DN1857754
- Practice address
- 334 Broadway
Revere, MA 02151-5016 - Phone
- (178) 162-9624
- NPI assigned
- Sep 27, 2017
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | DN1857754 | MA | Primary |
Addresses
Primary practice location
334 Broadway
Revere, MA 02151-5016
Mailing address
99 Florence Street
Apt 102
Malden, MA 02148
Phone (203) 548-1113
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180531000221 | MA | Order and Referring Only - Dentist | 4981969516 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DN1857754 | MA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1506470400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1506470400000",
"number": "1124537667",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "99 FLORENCE STREET",
"address_2": "APT 102",
"city": "MALDEN",
"state": "MA",
"postal_code": "02148",
"telephone_number": "203-548-1113"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "334 BROADWAY",
"city": "REVERE",
"state": "MA",
"postal_code": "021515016",
"telephone_number": "178-162-9624"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACOB",
"first_name": "MARY",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2017-09-27",
"last_updated": "2017-09-27",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MA",
"license": "DN1857754",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Revere, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.