Provider Demographics
NPI:1740409986
Name:JACOBSON, WAYNE STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:STEVEN
Last Name:JACOBSON
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 1:1440 MAPLE AVE
Mailing Address - Street 2:3A
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-4134
Mailing Address - Country:US
Mailing Address - Phone:630-963-9280
Mailing Address - Fax:
Practice Address - Street 1:1440 MAPLE AVE
Practice Address - Street 2:3A
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-4134
Practice Address - Country:US
Practice Address - Phone:630-963-9280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190151311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice