Provider Demographics
NPI:1043370414
Name:LUDWIG, JACOBI LAZAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOBI
Middle Name:LAZAR
Last Name:LUDWIG
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 1:217 W LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1867
Mailing Address - Country:US
Mailing Address - Phone:805-529-0100
Mailing Address - Fax:
Practice Address - Street 1:1905 PLAZA DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2883
Practice Address - Country:US
Practice Address - Phone:651-686-6678
Practice Address - Fax:805-529-0102
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120851223G0001X
CA632281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN78420600Medicaid