Provider Demographics
NPI:1942758180
Name:BRIAN J JACOBSEN DMD PC
Entity Type:Organization
Organization Name:BRIAN J JACOBSEN DMD PC
Other - Org Name:JACOBSEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-754-3262
Mailing Address - Street 1:103 1ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1842
Mailing Address - Country:US
Mailing Address - Phone:509-754-3262
Mailing Address - Fax:509-754-4975
Practice Address - Street 1:103 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-1842
Practice Address - Country:US
Practice Address - Phone:509-754-3262
Practice Address - Fax:509-754-4975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60128176122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty