Provider Demographics
NPI:1265453013
Name:JACOBSON, DAVID ORLAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ORLAN
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:ORLAN
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2525 N 8TH ST
Mailing Address - Street 2:STE 107
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501
Mailing Address - Country:US
Mailing Address - Phone:970-257-7474
Mailing Address - Fax:719-257-7481
Practice Address - Street 1:2525 N 8TH ST
Practice Address - Street 2:STE 107
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-257-7474
Practice Address - Fax:719-257-7481
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO88021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94536066Medicaid
1678469OtherUNITED CONCORDIA