Provider Demographics
NPI:1346484094
Name:BENNETT JACOBY DDS MS INC.
Entity Type:Organization
Organization Name:BENNETT JACOBY DDS MS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:808-329-7246
Mailing Address - Street 1:PO BOX 75407294
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57186-2119
Mailing Address - Country:US
Mailing Address - Phone:808-960-5991
Mailing Address - Fax:
Practice Address - Street 1:2978 HALEKO RD
Practice Address - Street 2:STE A
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1379
Practice Address - Country:US
Practice Address - Phone:808-960-5991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT2112251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management