Healthcare Provider Details

I. General information

NPI: 1841360195
Provider Name (Legal Business Name): EGILL LARS JACOBSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 S ADDISON RD SUITE 103
ADDISON IL
60101-3868
US

IV. Provider business mailing address

210 W ELM PARK AVE
ELMHURST IL
60126-3230
US

V. Phone/Fax

Practice location:
  • Phone: 630-941-3316
  • Fax: 630-941-7020
Mailing address:
  • Phone: 630-834-7617
  • Fax: 630-941-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: