Provider Demographics
NPI:1235331273
Name:JACOBY, BENNETT
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:
Last Name:JACOBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75407294
Mailing Address - Street 2:STE. A
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57186-1379
Mailing Address - Country:US
Mailing Address - Phone:808-202-2060
Mailing Address - Fax:
Practice Address - Street 1:2978 HALEKO RD
Practice Address - Street 2:STE A
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1379
Practice Address - Country:US
Practice Address - Phone:808-202-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT21121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics