Stacy Jacob, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

30.026177 Issued in OH

Practice address

15711 Madison Ave Ste 104
Lakewood, OH 44107-5655

Phone

(216) 228-7950

Fax

(216) 228-7951

NPI assigned

Jun 27, 2020

Last updated

Jun 27, 2020By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Lakewood City Center Dental LLC

  • Dental Clinic/Center
  • Lakewood, OH
  • NPI 1710504592
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1593216000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1593216000000",
    "number": "1275150013",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15711 MADISON AVE STE 104",
            "city": "LAKEWOOD",
            "state": "OH",
            "postal_code": "441075655",
            "telephone_number": "216-228-7950",
            "fax_number": "216-228-7951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15711 MADISON AVE STE 104",
            "city": "LAKEWOOD",
            "state": "OH",
            "postal_code": "441075655",
            "telephone_number": "216-228-7950",
            "fax_number": "216-228-7951"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACOB",
        "first_name": "STACY",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-06-27",
        "last_updated": "2020-06-27",
        "certification_date": "2020-06-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "OH",
            "license": "30.026177",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL LICENCE",
            "identifier": "30.026177",
            "state": "OH"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "lakewood15711@gmail.com",
            "affiliation": "N",
            "endpointDescription": "lakewood15711@gmail.com",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "15711 Madison Ave Ste 104",
            "city": "Lakewood",
            "state": "OH",
            "country_code": "US",
            "postal_code": "441075655",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Elizabeth Anne Isaac, DC
• Joan Chiaki Ishibashi, L.M.T.
• Michael R. Izquierdo, D.C.
• J. Thomas Corpus, M.D., Inc.
• Lanetta Jackson, LPN
• Mary Beth Jacobson, PA-C
• Alicia Jane Jadwisiak, LMT
• Ashley Jamison
• Polly L Jason, PEER SUPPORTER
• Nesreen Ghazi Jawhari, PNP-PC

• General Practice Dentistry in Lakewood, OH
• Providers in Lakewood, OH by specialty
• General Practice Dentistry in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.