Susanna Jacob, D.D.S
Individual provider Active NPI Dentist · Amenia, NY
NPI 1851775563 · NPPES record last updated Feb 5, 2016
Key facts
- NPI
- 1851775563
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 058297-1 (NY)
- Practice address
- 3360 Route 343
Amenia, NY 12501-5619 - Phone
- (845) 838-7038
- NPI assigned
- Jul 13, 2015
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NY
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160324001544 | NY | Order and Referring Only - Dentist |
5193022747 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 058297-1 | NY | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 058297-1 | NY | Yes |
Addresses
Primary practice location
3360 Route 343
Amenia, NY 12501-5619
Mailing address
3360 Route 343
Amenia, NY 12501-5619
Phone (845) 838-7038
Other providers in Amenia, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 5, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.