Provider Demographics
NPI:1750951703
Name:JACOBSON, BENJAMIN JAMES (DDS)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JAMES
Last Name:JACOBSON
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 1:1201 ASTER DR APT 304
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:IA
Mailing Address - Zip Code:52340-4304
Mailing Address - Country:US
Mailing Address - Phone:515-890-9605
Mailing Address - Fax:
Practice Address - Street 1:4141 GLASS RD NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-2512
Practice Address - Country:US
Practice Address - Phone:319-393-0773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09912122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist