Provider Demographics
NPI:1376975250
Name:IHLE, JACOB ISAAC (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ISAAC
Last Name:IHLE
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 1:40 N 1ST AVE E
Mailing Address - Street 2:SUITE #5
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1268
Mailing Address - Country:US
Mailing Address - Phone:218-365-3145
Mailing Address - Fax:
Practice Address - Street 1:40 N 1ST AVE E
Practice Address - Street 2:SUITE #5
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1268
Practice Address - Country:US
Practice Address - Phone:218-365-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13307122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist