Healthcare Provider Details

I. General information

NPI: 1437520988
Provider Name (Legal Business Name): JACOB STADIEM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9380 KENWOOD RD
BLUE ASH OH
45242-6810
US

IV. Provider business mailing address

9380 KENWOOD RD
BLUE ASH OH
45242-6810
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-4470
  • Fax:
Mailing address:
  • Phone: 513-793-4770
  • Fax: 513-793-4772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30.025621
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: