Healthcare Provider Details

I. General information

NPI: 1861131658
Provider Name (Legal Business Name): ALYSSA JACOBS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 W LINCOLN AVE
MADISON HEIGHTS MI
48071-3907
US

IV. Provider business mailing address

39242 DEQUINDRE RD STE 106
STERLING HEIGHTS MI
48310-1767
US

V. Phone/Fax

Practice location:
  • Phone: 248-542-8001
  • Fax:
Mailing address:
  • Phone: 586-795-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES.004489
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601446
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: