Provider Demographics
NPI:1760657795
Name:JACOBSEN, STEVEN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:ROBERT
Last Name:JACOBSEN
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 1:4801 HWY 61
Mailing Address - Street 2:#300
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110
Mailing Address - Country:US
Mailing Address - Phone:651-429-2299
Mailing Address - Fax:651-429-6630
Practice Address - Street 1:4801 HWY 61
Practice Address - Street 2:#300
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-429-2299
Practice Address - Fax:651-429-6630
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics