Provider Demographics
NPI:1134732100
Name:KAUFMAN, JACOB R (DMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:KAUFMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 NE DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5629
Mailing Address - Country:US
Mailing Address - Phone:503-476-7660
Mailing Address - Fax:
Practice Address - Street 1:12596 SE STARK ST BLDG N
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1056
Practice Address - Country:US
Practice Address - Phone:503-252-9657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist