Provider Demographics
NPI:1225146855
Name:JAKSA, STEPHEN WILLIAM (DDS,)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WILLIAM
Last Name:JAKSA
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 1:4801 HIGHWAY 61 N
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2737
Mailing Address - Country:US
Mailing Address - Phone:651-762-8474
Mailing Address - Fax:651-762-7821
Practice Address - Street 1:4801 HIGHWAY 61 N
Practice Address - Street 2:SUITE 301
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2737
Practice Address - Country:US
Practice Address - Phone:651-762-8474
Practice Address - Fax:651-762-7821
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice