Provider Demographics
NPI:1528077435
Name:JACOBSON, STEPHEN ERIC (DDS PC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ERIC
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39890 W 14 MILE RD.
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3911
Mailing Address - Country:US
Mailing Address - Phone:248-624-8090
Mailing Address - Fax:248-479-8122
Practice Address - Street 1:39890 W 14 MILE RD.
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3911
Practice Address - Country:US
Practice Address - Phone:248-624-8090
Practice Address - Fax:248-624-8288
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI142571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI723815OtherUNITED CONCORDIA