Provider Demographics
NPI:1588823983
Name:YETZER, JACOB GREGORY (MD, DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:GREGORY
Last Name:YETZER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:3366 OAKDALE AVE N STE 200
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2962
Practice Address - Country:US
Practice Address - Phone:763-581-5360
Practice Address - Fax:763-581-5361
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119107204E00000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003147783AMedicaid
FL011938600Medicaid
GA003147783AMedicaid