Provider Demographics
NPI:1700839032
Name:JACOBS, KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
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 1:8641 WILSHIRE BL
Mailing Address - Street 2:#315
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211
Mailing Address - Country:US
Mailing Address - Phone:310-657-0411
Mailing Address - Fax:310-657-4037
Practice Address - Street 1:8641 WILSHIRE BLVD
Practice Address - Street 2:315
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2900
Practice Address - Country:US
Practice Address - Phone:310-657-0411
Practice Address - Fax:310-657-4037
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA343491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice