Provider Demographics
NPI:1184355349
Name:MEYER, JACOB DANIEL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:MEYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 104TH LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1556
Mailing Address - Country:US
Mailing Address - Phone:651-707-6607
Mailing Address - Fax:
Practice Address - Street 1:12904 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4147
Practice Address - Country:US
Practice Address - Phone:763-755-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist