MEDICARE: DR. JOAN MARIE JAKUBAS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	10142	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	836516	OTHER	MN	UNITED CONCORDIA
2	012466	OTHER	MN	UCARE
3	Z97489	OTHER	MA	BLUE CROSS BLUE SHIELD MA
4	45616JA	OTHER	MN	BLU CROSS BLUE SHIELD MN

General Provider Information

NPI Number	:	1093806598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOAN MARIE JAKUBAS D.D.S.

Provider Business Mailing Address
First Line	:	4721 HIAWATHA AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-3928
Country	:	US
Telephone Number	:	612-721-3012
Fax Number	:	612-721-5106

Provider Business Practice Location Address
First Line	:	4721 HIAWATHA AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-3928
Country	:	US
Telephone Number	:	612-721-3012
Fax Number	:	612-721-5106

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/09/2007

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