Provider Demographics
NPI:1265841415
Name:GARY B JACOBSEN DDS, A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:GARY B JACOBSEN DDS, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-445-8048
Mailing Address - Street 1:301 W HUNTINGTON DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3462
Mailing Address - Country:US
Mailing Address - Phone:626-445-8048
Mailing Address - Fax:626-445-8128
Practice Address - Street 1:301 W HUNTINGTON DR
Practice Address - Street 2:SUITE 204
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3462
Practice Address - Country:US
Practice Address - Phone:626-445-8048
Practice Address - Fax:626-445-8128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26077261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295885382OtherINDIVIDUAL NPI NUMBER