Provider Demographics
NPI:1457791915
Name:JAKUBOWICZ, PHILLIP A (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:JAKUBOWICZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 KRIDER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9018
Mailing Address - Country:US
Mailing Address - Phone:574-535-3428
Mailing Address - Fax:
Practice Address - Street 1:103 OSCEOLA AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-2209
Practice Address - Country:US
Practice Address - Phone:574-674-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012014A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist