Provider Demographics
NPI:1770933913
Name:SZYMANSKI, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SZYMANSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11552 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2644
Mailing Address - Country:US
Mailing Address - Phone:586-573-7500
Mailing Address - Fax:
Practice Address - Street 1:11552 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2644
Practice Address - Country:US
Practice Address - Phone:586-573-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-19
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021959122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901021959Medicaid
MI2901021959Medicare UPIN
MI2901021959Medicare PIN
MI2901021959Medicare NSC
MI2901021959Medicaid