Provider Demographics
NPI:1437266905
Name:JACOBSON, BOYD LEE (DDS, MS)
Entity Type:Individual
Prefix:
First Name:BOYD
Middle Name:LEE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 DAISY DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GREEN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-9768
Mailing Address - Country:US
Mailing Address - Phone:801-829-5528
Mailing Address - Fax:
Practice Address - Street 1:1508 E SKYLINE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4846
Practice Address - Country:US
Practice Address - Phone:801-479-7069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT322036-99231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics