Provider Demographics
NPI:1629694963
Name:HELD, JACOB JOHN DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOHN DALE
Last Name:HELD
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 1:17751 96TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1272
Mailing Address - Country:US
Mailing Address - Phone:320-828-0302
Mailing Address - Fax:
Practice Address - Street 1:6563 LAKETOWNE PL
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4510
Practice Address - Country:US
Practice Address - Phone:763-515-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist