Provider Demographics
NPI:1427788975
Name:JACOBSEN, MICHAEL L
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:JACOBSEN
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 1:12587 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8308
Mailing Address - Country:US
Mailing Address - Phone:760-951-7752
Mailing Address - Fax:
Practice Address - Street 1:12587 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8308
Practice Address - Country:US
Practice Address - Phone:760-951-7752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics