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General NPI Number Information
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NPI Number | 1154480002
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Entity Type | Organization
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Legal Business Name | COMPREHENSIVE DENTAL SERVICES LTD
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 10521 N PORT WASHINGTON RD SUITE 200
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City | MEQUON
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State | WI
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Zip | 53092
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Country | US
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Telephone | 262-241-2060
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Fax | 262-241-2064
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Provider Business Mailing Address
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Address Line | 10521 N PORT WASHINGTON RD SUITE 200
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City | MEQUON
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State | WI
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Zip | 53092
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Country | US
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Telephone | 262-241-2060
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Fax | 262-241-2064
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. MARC JACOBSON
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Credential | DDS
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Telephone | 262-241-2060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2475-015
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License Number State | WI
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