Provider Demographics
NPI:1225678139
Name:ERIC E JACOBSEN DDS PC
Entity Type:Organization
Organization Name:ERIC E JACOBSEN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-562-5564
Mailing Address - Street 1:19502 MOLALLA AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4513
Mailing Address - Country:US
Mailing Address - Phone:503-656-0405
Mailing Address - Fax:503-344-4295
Practice Address - Street 1:19502 MOLALLA AVE STE 109
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4513
Practice Address - Country:US
Practice Address - Phone:503-656-0405
Practice Address - Fax:503-344-4295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ERIC E JACOBSEN DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty