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General NPI Number Information
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NPI Number | 1457877011
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Entity Type | Individual
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Provider Name | MILES J JACOBSEN DDS
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Gender | Male
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Dates
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Enumeration Date | 08/16/2017
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Last Update Date | 08/16/2017
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Provider Practice Location Address
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Address Line | 2838 N OLIVER ST
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City | WICHITA
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State | KS
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Zip | 67220-2983
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Country | US
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Telephone | 316-978-8350
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Fax |
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Provider Business Mailing Address
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Address Line | 10437 E FAWN GROVE CT
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City | WICHITA
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State | KS
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Zip | 67207-4364
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Country | US
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Telephone | 316-644-3298
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 61458
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License Number State | KS
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