Provider Demographics
NPI:1326375437
Name:JACOBSON, MARK S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
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 1:800 ROSE ST RM D632
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0297
Mailing Address - Country:US
Mailing Address - Phone:859-323-5995
Mailing Address - Fax:859-323-0066
Practice Address - Street 1:800 ROSE ST RM D632
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0297
Practice Address - Country:US
Practice Address - Phone:859-323-5995
Practice Address - Fax:859-323-0066
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY79161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice