Provider Demographics
NPI:1164670501
Name:ATKINSON, JACOB LORENZA (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LORENZA
Last Name:ATKINSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3201
Mailing Address - Country:US
Mailing Address - Phone:541-881-8700
Mailing Address - Fax:
Practice Address - Street 1:475 SW 12TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3201
Practice Address - Country:US
Practice Address - Phone:541-881-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist