Provider Demographics
NPI:1457877011
Name:JACOBSEN, MILES J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MILES
Middle Name:J
Last Name:JACOBSEN
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 1:10437 E FAWN GROVE CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-4364
Mailing Address - Country:US
Mailing Address - Phone:316-644-3298
Mailing Address - Fax:
Practice Address - Street 1:2838 N OLIVER ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2983
Practice Address - Country:US
Practice Address - Phone:316-978-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61458122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist