Provider Demographics
NPI:1033720602
Name:KERKERING, JACOB MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:KERKERING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 PROMENADE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-4420
Mailing Address - Country:US
Mailing Address - Phone:651-236-7458
Mailing Address - Fax:651-405-6995
Practice Address - Street 1:3405 PROMENADE AVE STE 300
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-4420
Practice Address - Country:US
Practice Address - Phone:651-236-7458
Practice Address - Fax:651-405-6995
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND144711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice