Provider Demographics
NPI:1821120122
Name:JACOBSON, RONALD (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W PETERSON AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6074
Mailing Address - Country:US
Mailing Address - Phone:773-545-5333
Mailing Address - Fax:773-545-3636
Practice Address - Street 1:4200 W PETERSON AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6074
Practice Address - Country:US
Practice Address - Phone:773-545-5333
Practice Address - Fax:773-545-3636
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210014681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01901183OtherLICENSE NUMBER
IL363504828OtherTIN