Provider Demographics
NPI:1275675951
Name:JACOBS, LAURIE B (DMD PA)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:B
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 FOULK RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3734
Mailing Address - Country:US
Mailing Address - Phone:302-764-7714
Mailing Address - Fax:
Practice Address - Street 1:708 FOULK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3734
Practice Address - Country:US
Practice Address - Phone:302-764-7714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00009091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000651508Medicaid