Provider Demographics
NPI:1235292046
Name:JAKOBSEN, CHARLES BRYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRYAN
Last Name:JAKOBSEN
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 1:4044 W ALEX LOOP
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-2444
Mailing Address - Country:US
Mailing Address - Phone:623-209-4780
Mailing Address - Fax:623-581-0793
Practice Address - Street 1:4130 N 108TH AVE
Practice Address - Street 2:SUITE 103-104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5774
Practice Address - Country:US
Practice Address - Phone:623-772-9600
Practice Address - Fax:623-772-9601
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice