Provider Demographics
NPI:1508172107
Name:LILJENQUIST, JACOB VAUGHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:VAUGHN
Last Name:LILJENQUIST
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 1:9435 CASTLE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4517
Mailing Address - Country:US
Mailing Address - Phone:702-426-7558
Mailing Address - Fax:
Practice Address - Street 1:1000 N 8TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5757
Practice Address - Country:US
Practice Address - Phone:208-232-3368
Practice Address - Fax:208-776-5016
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7754866-99211223G0001X, 122300000X
WADE60162914122300000X
IDD48111223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health