Provider Demographics
NPI:1386079689
Name:JACOBS, BRYAN (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E WACKER DR UNIT 4112
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5274
Mailing Address - Country:US
Mailing Address - Phone:734-276-9804
Mailing Address - Fax:
Practice Address - Street 1:4905 OLD ORCHARD CTR STE 728
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-4734
Practice Address - Country:US
Practice Address - Phone:847-676-1432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0296151223P0700X
MI29010202691223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics