MEDICARE: STEPHEN ERIC JACOBSON D.D.S. PC

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	1223G0001X	General Practice Dentistry	14257	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	723815	OTHER	MI	UNITED CONCORDIA

General Provider Information

NPI Number	:	1528077435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN ERIC JACOBSON D.D.S. PC

Provider Business Mailing Address
First Line	:	39890 W 14 MILE RD.
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3911
Country	:	US
Telephone Number	:	248-624-8090
Fax Number	:	248-479-8122

Provider Business Practice Location Address
First Line	:	39890 W 14 MILE RD.
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3911
Country	:	US
Telephone Number	:	248-624-8090
Fax Number	:	248-624-8288

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

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	05/04/2022

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