Provider Demographics
NPI:1790162014
Name:JACOBSON, WILLIAM (DMD, MPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 W BALTIMORE ST STE 5201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1510
Mailing Address - Country:US
Mailing Address - Phone:410-706-4028
Mailing Address - Fax:
Practice Address - Street 1:650 W BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1510
Practice Address - Country:US
Practice Address - Phone:410-706-4028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17896122300000X
OH30.0269381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty