Provider Demographics
NPI:1265827588
Name:JACOBS, TODD MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:MICHAEL
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SHANNON DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3353
Mailing Address - Country:US
Mailing Address - Phone:859-394-2899
Mailing Address - Fax:
Practice Address - Street 1:200 ALBERT SABIN WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-2800
Practice Address - Country:US
Practice Address - Phone:859-394-2899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY103941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program