Healthcare Provider Details

I. General information

NPI: 1588823983
Provider Name (Legal Business Name): JACOB GREGORY YETZER M.D., D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 12/11/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 RADIO DRIVE SUITE A
WOODBURY MN
55125-0001
US

IV. Provider business mailing address

251 RADIO DRIVE SUITE A
WOODBURY MN
55125-0001
US

V. Phone/Fax

Practice location:
  • Phone: 651-760-3661
  • Fax:
Mailing address:
  • Phone: 651-760-3661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME119107
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS93
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: