Provider Demographics
NPI:1154480002
Name:COMPREHENSIVE DENTAL SERVICES LTD
Entity Type:Organization
Organization Name:COMPREHENSIVE DENTAL SERVICES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-241-2060
Mailing Address - Street 1:10521 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-241-2060
Mailing Address - Fax:262-241-2064
Practice Address - Street 1:10521 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-241-2060
Practice Address - Fax:262-241-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2475-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33412900Medicaid
WI33378400Medicaid