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General NPI Number Information
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NPI Number | 1831103175
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Entity Type | Organization
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Legal Business Name | MICHAEL L. JACOBSEN, D.D.S., M.S., INC.
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Dates
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Enumeration Date | 07/29/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12587 HESPERIA RD STE A
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City | VICTORVILLE
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State | CA
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Zip | 92395-5847
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Country | US
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Telephone | 760-951-7752
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Fax | 760-951-5446
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Provider Business Mailing Address
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Address Line | 12587 HESPERIA RD STE A
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City | VICTORVILLE
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State | CA
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Zip | 92395-5847
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Country | US
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Telephone | 760-951-7752
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Fax | 760-951-5446
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL JACOBSEN
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Credential |
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Telephone | 760-951-7752
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 30185
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License Number State | CA
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