Provider Demographics
NPI:1437319803
Name:JACOBSON, ALLEN (DDS, MDS)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11005 FIRESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2224
Mailing Address - Country:US
Mailing Address - Phone:562-863-8888
Mailing Address - Fax:
Practice Address - Street 1:11005 FIRESTONE BLVD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2224
Practice Address - Country:US
Practice Address - Phone:562-863-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA582101223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program