Provider Demographics
NPI:1942652185
Name:SON, JACOB STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:STEVEN
Last Name:SON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N72W13524 LUND LN UNIT 208
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-6122
Mailing Address - Country:US
Mailing Address - Phone:765-427-6605
Mailing Address - Fax:
Practice Address - Street 1:27132 MAIN ST UNIT 200
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-8523
Practice Address - Country:US
Practice Address - Phone:920-287-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001352 - 151223G0001X
CODEN.00204151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice