Provider Demographics
NPI:1326113127
Name:JACOBSON, TIMOTHY DALE (DDS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DALE
Last Name:JACOBSON
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 1:1411 W SAINT GERMAIN ST
Mailing Address - Street 2:SUITE #103
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4121
Mailing Address - Country:US
Mailing Address - Phone:320-253-2121
Mailing Address - Fax:
Practice Address - Street 1:1411 W SAINT GERMAIN ST
Practice Address - Street 2:SUITE #103
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4121
Practice Address - Country:US
Practice Address - Phone:320-253-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist