Provider Demographics
NPI:1518117498
Name:STEPHEN E JACOBSON DDS PC
Entity Type:Organization
Organization Name:STEPHEN E JACOBSON DDS PC
Other - Org Name:JACOBSON DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:248-624-8090
Mailing Address - Street 1:39890 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3911
Mailing Address - Country:US
Mailing Address - Phone:248-624-8090
Mailing Address - Fax:248-624-8288
Practice Address - Street 1:39890 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48390-3911
Practice Address - Country:US
Practice Address - Phone:248-624-8090
Practice Address - Fax:248-624-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI142571223G0001X
MI185531223G0001X
MI167581223G0001X
MI189131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty