Provider Demographics
NPI:1346863131
Name:DAWSON, JACOB (DMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DAWSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:
Practice Address - Street 1:5709 NW RADIAL HWY
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-4141
Practice Address - Country:US
Practice Address - Phone:402-551-1757
Practice Address - Fax:402-551-4384
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7280122300000X
NE7759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist