Provider Demographics
NPI:1184751125
Name:JACOBSON, RICHARD LESLIE (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LESLIE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 ALMA REAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3731
Mailing Address - Country:US
Mailing Address - Phone:310-454-0317
Mailing Address - Fax:310-459-3826
Practice Address - Street 1:881 ALMA REAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3731
Practice Address - Country:US
Practice Address - Phone:310-454-0317
Practice Address - Fax:310-459-3826
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADJ0293081223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU31097Medicare UPIN
CAD29308Medicare ID - Type Unspecified