Provider Demographics
NPI:1154017432
Name:DES JARDINS, JACOB WILLIAM
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLIAM
Last Name:DES JARDINS
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 1:4555 ERIN DR STE 180
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3334
Mailing Address - Country:US
Mailing Address - Phone:651-681-9044
Mailing Address - Fax:
Practice Address - Street 1:4555 ERIN DR STE 180
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3334
Practice Address - Country:US
Practice Address - Phone:651-681-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND149421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice