Provider Demographics
NPI:1831103175
Name:MICHAEL L. JACOBSEN, D.D.S., M.S., INC.
Entity Type:Organization
Organization Name:MICHAEL L. JACOBSEN, D.D.S., M.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-951-7752
Mailing Address - Street 1:12587 HESPERIA RD STE A
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5847
Mailing Address - Country:US
Mailing Address - Phone:760-951-7752
Mailing Address - Fax:760-951-5446
Practice Address - Street 1:12587 HESPERIA RD STE A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5847
Practice Address - Country:US
Practice Address - Phone:760-951-7752
Practice Address - Fax:760-951-5446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty