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 1:251 RADIO DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-0001
Mailing Address - Country:US
Mailing Address - Phone:651-760-3661
Mailing Address - Fax:
Practice Address - Street 1:251 RADIO DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-0001
Practice Address - Country:US
Practice Address - Phone:651-760-3661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119107204E00000X
MNS931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003147783AMedicaid
FL011938600Medicaid
GA003147783AMedicaid