Provider Demographics
NPI:1790982502
Name:JACOBSEN, GINA MIRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:MIRA
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:MIRA
Other - Last Name:SBALCHIERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1940 W GALENA BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4319
Mailing Address - Country:US
Mailing Address - Phone:630-892-8933
Mailing Address - Fax:
Practice Address - Street 1:1940 W GALENA BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4319
Practice Address - Country:US
Practice Address - Phone:630-892-8933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-027370122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist