Provider Demographics
NPI:1508984576
Name:JACOBSON, DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JACOBSON
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 1:1011 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:734-763-1379
Mailing Address - Fax:734-647-4024
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-763-1379
Practice Address - Fax:734-647-4024
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015040122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2667814Medicaid
MI195816277OtherBCBS OF MI MED SURGICAL
MID015040OtherBCBS OF MI DENTAL
MID015040OtherBCBS OF MI DENTAL
MI0P16890002Medicare PIN