Provider Demographics
NPI:1851815310
Name:JACOB L. BARTHOLD DDS, PA
Entity Type:Organization
Organization Name:JACOB L. BARTHOLD DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BARTHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-746-6567
Mailing Address - Street 1:107 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56283-1621
Mailing Address - Country:US
Mailing Address - Phone:763-746-6567
Mailing Address - Fax:
Practice Address - Street 1:69 LAKE ST N STE 100
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2527
Practice Address - Country:US
Practice Address - Phone:763-746-6567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13073261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1457613028Medicaid