Provider Demographics
NPI:1225108020
Name:JACOBSEN, SOREN H (DDS)
Entity Type:Individual
Prefix:DR
First Name:SOREN
Middle Name:H
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:SOREN
Other - Middle Name:H
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA DDS
Mailing Address - Street 1:2830 N 1050 E
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4033
Mailing Address - Country:US
Mailing Address - Phone:530-510-1186
Mailing Address - Fax:801-766-1066
Practice Address - Street 1:2830 N 1050 E
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4033
Practice Address - Country:US
Practice Address - Phone:530-510-1186
Practice Address - Fax:801-766-1066
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6829299122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist