Provider Demographics
NPI:1609930270
Name:JACOBS, LAWRENCE T (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:T
Last Name:JACOBS
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 1:8235 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60171-1539
Mailing Address - Country:US
Mailing Address - Phone:708-453-0250
Mailing Address - Fax:
Practice Address - Street 1:8235 GRAND AVE
Practice Address - Street 2:
Practice Address - City:RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60171-1539
Practice Address - Country:US
Practice Address - Phone:708-453-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice