Provider Demographics
NPI:1326275462
Name:SORENSEN, JACOB DEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DEAN
Last Name:SORENSEN
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 1:800 1ST AVE N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-1725
Mailing Address - Country:US
Mailing Address - Phone:641-357-8111
Mailing Address - Fax:641-357-7713
Practice Address - Street 1:800 1ST AVE N
Practice Address - Street 2:SUITE 2
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-1725
Practice Address - Country:US
Practice Address - Phone:641-357-8111
Practice Address - Fax:641-357-7713
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA086471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice